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http://dx.doi.org/10.1037/0000064-006 APA Handbook of Psychopathology: Vol. 1. Psychopathology: Understanding, Assessing, and Treating Adult Mental Disorders, J. N. Butcher (Editor-in-Chief) Copyright © 2018 by the American Psychological Association. All rights reserved.

Sociocultural factors influence the development, presentation, classification, and assessment of psy- chological disorders. Emotional and behavioral dis- orders are closely tied to the social world. Although mental disorders have universal commonalities, psy- chopathology is embedded in socioculturally based systems of meaning and values. Social and cultural variations are found in the formation, expression, labeling, and treatment of symptom experiences.

SOCIOCULTURAL PERSPECTIVES IN DIAGNOSTIC SYSTEMS

Sociocultural factors influence the development, pre- sentation, classification, and assessment of psycho- logical disorders. Emotional and behavioral disorders are closely tied to the social world. While there are universal commonalities in mental disorders, psy- chopathology is embedded in socioculturally based systems of meaning and values. Social and cultural variations are found in the formation, expression, labeling, and treatment of symptom experiences.

Sociocultural Influences as Determinants of Mental Health Disparities In any society, mental health disparities have been well documented across class, race/ethnicity, gen- der, and sexual orientation, among many other sociocultural determinants in prevalence and clini- cal diagnosis (Garb, 1997). Across epidemiological

studies conducted in the United States and in the United Kingdom, less privileged social position was found to be associated with higher prevalence of common mental disorders among women and men, with unemployment, less education, and lower income having stronger association than occupational status with common mental disor- ders (Fryers, Melzer, & Jenkins, 2003). Such social gradient was also found across both genders on depression, psychological well-being, self-reported health, and smoking, with employment grade and years of education showing a stronger relationship than most recent occupational status (Marmot, Ryff, Bumpass, Shipley, & Marks, 1997). As to sexual orientation, based on the National Survey of Midlife Development conducted in the United States, gay and bisexual men were found to have higher preva- lence of depression, panic attacks, and overall psy- chological distress than heterosexual men; lesbian and bisexual women were found to have a higher prevalence of generalized anxiety disorder than heterosexual women (Cochran, Sullivan, & Mays, 2003). A systematic review showed that lesbian, gay, and bisexual individuals have higher risk for mental disorder, suicidal ideation, substance misuse, and deliberate self-harm (King et al., 2008). Consider- ing sexual orientation along with ethnicity, find- ings from the National Latino and Asian American Survey showed a higher prevalence of depressive disorders among Latino and Asian American lesbian

C h a P t e r 6

Sociocultural FactorS in PSychoPathology

Fanny M. Cheung and Winnie W. S. Mak

The writing of this chapter was partially supported by the Hong Kong Research Grants Council General Research Fund (Nos. CUHK4333/00H, CUHK4326/01H, and CUHK449312) as well as the Chinese University of Hong Kong Direct Grant (Nos. 2020662, 220202030, and 4052103).

APA Handbook of Psychopathology: Psychopathology: Understanding, Assessing, and Treating Adult Mental Disorders, edited by J. N. Butcher and J. M. Hooley Copyright © 2018 American Psychological Association. All rights reserved.

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and bisexual women than among their heterosexual counterparts (Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007). Such heightened risk for nonhet- erosexual individuals has been found to be related to perceived discrimination (Mays & Cochran, 2001) and minority stress (Meyer, 2003).

Intersectional effects among sociocultural sta- tuses on mental health were also found. On the basis of data from the Behavioral Risk Factor Surveillance System surveys from 1993 to 2001, although indi- viduals with high socioeconomic status reported the lowest level of frequent mental distress, prevalence differed by race/ethnicity, being highest among non- Hispanics of other race (7.9%), followed by Ameri- can Indians/Alaska Natives (7.7%), non-Hispanic Blacks (6.1%), Hispanics (5.9%), non-Hispanic Whites (4.7%), and Asians/Pacific Islanders (3.8%; Muntaner, Ng, Vanroelen, Christ, & Eaton, 2013; Zahran et al., 2005). In another study (Williams, Yu, Jackson, & Anderson, 1997), racial differences in psychological well-being were accounted for by economic status (income, education), race-related stressors (e.g., major experiences of discrimination and everyday discrimination), and general stress- ors (e.g., chronic stress, financial stress, and life events), with African Americans reporting higher levels of well-being than Whites. Thus, rather than investigating mental health disparities by any single identity or status, the intersectionality of multiple sociocultural identities or statuses should be consid- ered simultaneously to capture the nuances of and unique impact that multiple categories of identity, difference, and disadvantage have on individuals (Cole, 2009). Moreover, theoretical models such as social stress models should be applied and tested to disentangle the within- and between-group varia- tions that social inequalities have on mental health disparities (Aneshensel, 2009; Schwartz & Meyer, 2010). Disparities in the access to, utilization of, and outcomes of services should be considered, along with sociocultural biases in diagnosis and preva- lence of mental disorders (McGuire, Alegria, Cook, Wells, & Zaslavsky, 2006).

Culture and Psychopathology From an international perspective, theories of cul- ture and psychopathology have compared diversities

of psychopathology across cultures and examined the role of culture (including all the nonbiological aspects of the human social world) in causing or determining the conditions that lead to psychiatric disorders (Spiro, 2001). Other than the theory of cultural determinism, the concept of cultural relativ- ism proposes that the diversity in a mental disorder, the variability of symptoms presented in that disor- der, or the judgment of what constitutes pathology may be explained by cultural diversity.

Since Kleinman (1977) heralded the interdis- ciplinary research approach of cross-cultural psy- chiatry, Western diagnostic systems have begun to pay attention to indigenous illness categories and to recognize cultural limitations of some of the existing diagnostic nosologies that aim to provide a common language for mental health professionals to commu- nicate across cultural and social contexts. Kirmayer (2005) unequivocally warned that

psychiatric nosology and the process of clinical assessment must consider the ways in which psychopathology is shaped by social and cultural contexts including those of the family, workplace, and health care system as well as global professional, economic and political interests. (p. 192)

López and Guarnaccia (2000) summarized two major recent advances in the study of culture and psychopathology: the establishment of the task force funded by the National Institute of Mental Health to develop cultural materials to be incorporated into all sections of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; Mezzich et al., 1997), and the publication of the World Mental Health Report (Desjarlais, Eisenberg, Good, & Kleinman, 1996). Although these devel- opments advance the range of conceptualization of cultures and the importance of social domains, cultural psychopathology remains in the periphery of mainstream epistemology. Culture continues to be disconnected from theory, research, training, and intervention (Causadias, 2013).

Because a psychiatric diagnostic system aims to provide a universal nomenclature for clinicians and researchers across different settings to collect and

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communicate information, cultural considerations are requisite for the diagnostic classifications to be accurate and valid. The two most commonly adopted systems are the American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders (DSM) and the World Health Organization’s Interna- tional Classification of Diseases (ICD) mental disorder section. These contemporary systems are based in Western models of medicine, taking into account comprehensive reviews of the published literature and data sets, as well as extensive field tests on selected issues. Both systems have undergone periodic reviews and revisions. Instead of describing the classifications of these diagnostic systems, we focus on the cultural and sociocultural perspectives incorporated into the latest versions and discuss the critiques of the inad- equacies of and improvements in incorporating socio- cultural considerations into these systems.

Inclusion of Culture in DSM–IV and DSM–5 Early versions of the DSM have been criticized for their neglect of cultural relevance. Bias on the basis of a person’s race, ethnicity, class, gender, age, sexual orientation, religion, and other sociocultural influ- ences affects the accuracy of clinical judgment if the diagnosis is more valid for one group of persons than for other groups (Garb, 1997). These biases may arise from the lack of sensitivity to diversity issues in the diagnostic criteria, as well as from the clinicians’ lack of sensitivity when gathering and integrating the clinical information. In an effort to increase its cultural sensitivity, the text revision of the DSM–IV included an Outline for Cultural Formulation (OCF) of a person in the appendix, which includes the “cultural identity of the individual,” “cultural expla- nations of the individual’s illness,” “cultural factors related to the psychosocial environment and levels of functioning,” “cultural elements of the relationship between the individual and clinician,” and “overall cultural assessment for diagnosis and care” (Ameri- can Psychiatric Association, 2000, pp. 843–844). The appendix also included a glossary of 25 com- mon culture-bound syndromes to denote “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM–IV diagnostic category” (p. 844).

On the basis of an extensive literature review by experts in the field of cultural and mental health, materials related to the OCF written in English, Danish, Dutch, French, Norwegian, Spanish, and Swedish were accessed (Lewis-Fernández et al., 2014). The OCF was found to be useful in improv- ing the clinicians’ and psychiatrists’ accuracy in making clinical diagnoses and reducing the over- diagnosis of psychotic disorders among ethnocul- tural minorities. For example, findings in Canada demonstrated that the use of the OCF resulted in rediagnosis of 60% of 400 referrals (Kirmayer, Guzder, & Rousseau, 2014). In another study, 49% (34 of 70) of the patients were rediagnosed from psychotic disorder to non-psychotic disorder and 5% (12 of 253) patients from non-psychotic disor- der to psychotic disorder on the use of OCF-based assessment (Adeponle, Thombs, Groleau, Jarvis, & Kirmayer, 2012). Similar results were found in the Netherlands, where the OCF-based assessment was found to increase the validity of the Comprehensive Assessment of Symptoms and History in diagnosing schizophrenia and related disorders. Specifically, among Moroccan patients, the OCF-based Com- prehensive Assessment of Symptoms and History reached a 93% diagnostic agreement (κ= .79) com- pared with a 48% diagnostic agreement (κ = −.49) using the assessment without consideration of cul- tural factors (Zandi et al., 2008).

Moreover, the OCF has been used in medical training programs in Canada, Denmark, India, the Netherlands, Norway, Spain, Sweden, the United Kingdom, and the United States. Despite its wide adoption, difficulties were reported in determin- ing how to use the OCF in actual practice with which populations and at what times. Furthermore, how the information gathered can be effectively integrated within psychiatric formulation and for adaptation of clinical approaches to varied popula- tions was not clear (Lewis-Fernández et al., 2014). In addition, the application of the OCF took much more time, with some areas being redundant with standardized diagnostic assessment.

To address these concerns, the fifth edition of the DSM (DSM–5) has incorporated more extensive con- sideration of cultural perspectives by introducing a Cultural Formulation Interview to operationalize

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the revised OCF for the facilitation of actual gather- ing of cultural information for a systematic assess- ment. The DSM–5 Cross-Cultural Issues Subgroup used a person-centered, ethnographic approach in the development of a semistructured interview to guide the use of the OCF (Lewis-Fernández et al., 2014). It consists of a 16-item questionnaire along with 12 modules to address the issues raised in the OCF. It also includes an informant version to obtain sociocultural information from caregivers and fam- ily members (American Psychiatric Association, 2013). The Cultural Formulation Interview has gone through a field trial for further refinement in terms of conceptual relevance between patients and clinicians, fidelity to the format, and repetition in the questions (Aggarwal, Nicasio, DeSilva, Boiler, & Lewis-Fernández, 2013). Despite the subgroup’s efforts in reviewing previous practice and training in the development of Cultural Formulation Interview, it is noted that the viewpoints from Asian countries, specifically those from East Asian and Southeast Asian countries, were underrepresented in the dis- cussion. Stronger efforts should be made to include core representatives from this part of the world to consider varied sociocultural perspectives of differ- ent countries.

In discussing the cross-cultural use of the DSM–5 constructs, norms, and guidelines, Rounsaville et al. (2005) recognized the importance of paying attention to cultural perspective in the meaning of statements reflecting diagnostic or clinical criteria in different parts of the world. As a key “conceptual scaffolding” of environmental factors that act on genetic or neurobiological predispositions in a per- son’s life, culture is considered to be a contributing factor to the pathogenesis of mental disorders (p. 17). It is acknowledged that although core diag- nostic criteria may be universally applicable, there are cross-cultural variations in symptom definition and symptomatic manifestations.

Alarcón et al. (2005) presented the current cul- tural perspective that conceptualizes psychiatric knowledge and practice from a more comprehensive perspective of social, cultural, economic, politi- cal, and historical factors in the DSM–5 research agenda. The cultural variables proposed include ethnicity, language, education, religion, gender and

sexuality roles, values, migration and acculturation, socioeconomic status, and occupational hierarchies. They proposed five interrelated questions to guide the thematic research on the cultural perspective of diagnosis:

1. Has the right nosologic system been conceptualized?

2. Are the right diagnostic categories and criteria being used?

3. Has the diagnostic threshold been set at the right level?

4. Have the course and characteristics of disorders been correctly typified?

5. Are existing diagnostic criteria being employed in an unbiased and culturally appropriate way? (pp. 223–225)

These are useful questions not only to guide research but also in the diagnostic criteria and pro- cesses. However, the usefulness of these guiding questions depends on the sensitivity of researchers and practitioners to the importance of addressing these concerns.

Inclusion of Culture in ICD–10 and Revision As a member of the World Health Organization’s “family” of international classifications, the ICD provides a global standard for a health information system that facilitates international communication across the health sector. It is periodically reviewed with the aim of updating the scientific evidence, clinical utility, and public health usefulness. The lat- est version, the ICD–10, was adopted by the World Health Assembly in 1990.

The ICD–10 Classification of Mental and Behav- ioural Disorders (World Health Organization, 1993) took into account the viewpoints of the dif- ferent psychiatric traditions and involved exten- sive consultation with international psychiatric societies and experts. International field trials were conducted in about 40 countries to improve the psychiatric diagnostic criteria. Associated diag- nostic instruments with training tools in different languages were developed, and a set of Diagnostic Criteria for Research was designed for research use in different countries.

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In addition to the universal diagnostic catego- ries, the annex in the ICD–10 lists 12 frequently described culture-specific disorders that share the following characteristics:

(1) they are not easily accommodated by the cat- egories in established and internationally used psychiatric classifications;

(2) they were first described in, and subsequently closely or exclusively associated with, a particu- lar population or cultural area. (World Health Organization, 1993, p. 213)

Recognizing the skepticism of some researchers toward the culture specificity of these culture-bound syndromes, ICD–10 provides a description of the clinical features for each of these disorders, sug- gested ICD–10 codes that may be related to these labels, and identified potentially related syndromes in other cultures. Noting the lack of reliable clini- cal, anthropological, epidemiological, and biologi- cal information on these culture-specific disorders, further cultural and cross-cultural research is rec- ommended before clear diagnostic criteria can be established. This approach to culture-specific disor- ders provides a useful framework to facilitate further research on cultural variations in the clinical mani- festations, distributions, frequency, and course of these syndromes, so as to fine tune the lexical defini- tions of the taxonomy in cross-cultural psychiatry.

Preparation for the 11th revision of the ICD (ICD–11) has involved input from international stakeholders. The framework for the deliberation of the topical advisory groups includes greater atten- tion to cultural elements and how the presentation of disorders varies across cultures. The work groups have also been directed to “identify ways to achieve cross-cultural comparability and utility of diagnostic criteria rather than listing separate culture-bound syndromes or formulations” (WHOFIC Network, 2007, p. 15). International teams conduct field tri- als to test the provisional revised diagnostic criteria. This iterative process is intended to broaden the cul- tural perspective of the diagnostic taxonomy and the universal applicability of the diagnostic criteria. The ICD–11 is due to be published by 2018.

Notwithstanding the recent efforts to broaden the cultural perspectives in the diagnostic criteria

of the DSM–5 and ICD–11, greater attention is also needed to enhance the cultural sensitivity of practitioners and researchers in their diagnosis and clinical assessment of individuals from diverse back- grounds. We discuss these training needs in the last section of this chapter.

Culture-Bound Syndromes: Controversies and Resolutions The inclusion of culture-bound syndromes in the annexes of the DSM–IV and ICD–10 is perceived to be the primary cultural focus of these diagnostic systems. These indigenous expressions of mental afflictions usually have local names that may not be found in Western psychiatric lexicons. The topic of culture-bound syndromes has its own controversies. On one hand, some researchers have challenged whether culture-bound syndromes can be seen as variants of Western disorders contextualized in non-Western cultures and not as special categories indigenous to specific cultures. On the other hand, putting these culture-bound syndromes in the annexes gives the impression that they are relegated to an exotic category of curiosity.

Marsella and Yamada (2010) questioned why “those identified and coded in the West in DSMs and ICDs are considered the real thing” (p. 107), whereas both could be considered cultural products in their respective cultures. Cheung (1998) discussed the controversy of these culture-bound syndromes in the context of emic versus etic approaches. Instead of being engulfed in the emic-versus-etic debate (Cheung, 2012) and regarding culture-specific disor- ders as bound to a particular culture, she suggested that the usefulness of these culture-related syndromes lies in their provision of better understanding of the cultural context of psychopathology, particularly those that are unfamiliar to Western models. She cited the transformation of neurasthenia from an out- dated Western psychiatric nomenclature to a popu- lar diagnostic term in Chinese, shenjing shuairuo, adopted in traditional Chinese medicine as well as in Chinese psychiatry, until recent years when literacy on emotional disorders increased with the modern- ization of Chinese societies (Cheung, 1989). Through the attention to less stigmatizing somatic symptoms attributed to socially acceptable causes of overwork

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and bodily imbalance, the adoption of this diagnos- tic label provides useful clinical understanding of patients’ illness experience and their social contexts (Cheung, 1998).

In the DSM–5 (American Psychiatric Association, 2013), culture-bound syndromes are replaced by cultural syndromes, cultural idioms of distress, and cultural explanations to further delineate the impact of sociocultural factors in the expression and com- munication of distress that reflect specific symptom clusters (syndromes), common expressions of dis- tress that may not have specific symptoms (idioms), and causal models that are used to understand and interpret their experience (cultural explanations; Lewis-Fernández et al., 2014). In the next section, we further discuss the phenomenon of somatization among Chinese patients to illustrate the cultural contextualization of mental distress.

Example of Chinese Somatization Tendency The phenomenon of Chinese somatization serves as an illustrative example of the potential pitfalls of “category fallacy,” the unwarranted assumption that a Western psychiatric diagnosis carries the same meaning when extended to another cultural context (Kleinman, 1986). The understanding of how cul- ture interacts with formal diagnostic categories to create alternative frames of meaning would enhance practitioners’ and researchers’ clinical sensitivity.

In the early stage of cultural psychiatry, the tendency of Chinese patients to present their depression in the form of somatic symptoms was highlighted (Kleinman, 1977). References were then made to various aspects of Chinese culture to attribute this somatic tendency without strong empirical evidence. Cheung (1998) disputed these post hoc cultural hypotheses and showed through various studies that Chinese patients were cogni- zant of their emotional distress but would report their somatic symptoms as “idioms of distress” (Kleinman, 1986) to doctors in the context of medical consultation. They would acknowledge their emotional symptoms when asked and pre- ferred to seek emotional support from their peers and family instead of from medical professionals (Cheung, Lau, & Wong, 1984). In another study

among Chinese American patients in primary care, although most of them (93%) endorsed depressed mood using the Beck Depression Inventory, only 10% labeled their experience as psychiatrically related (Yeung, Chang, Gresham, Nierenberg, & Fava, 2004). Thus, patients’ illness experience depends on the contextual factors that affect how they seek help for it. Instead of replacing their psychological distress with somatic symptoms, Chinese are reporting different types of symptoms depending on the reporting situation and their routes of help seeking (Mak & Chen, 2010). Such tendencies are more salient among immigrant populations and those with lower socioeconomic status who have not been “psychologized” by the Western cultures. Chinese who somatized were also found to experience more stressors and less social support than their counterparts (Mak & Zane, 2004). Thus, the experience of somatization might be an idiom of distress resulting from exces- sive stressors and a lack of social support in coping with them. It also hinges on the explanatory mod- els used by Chinese who somatized in attributing their symptoms.

The somatization tendencies observed among the Chinese may also be related to a distinct cul- tural syndrome, referred to as neurasthenia or shen- jing shuairuo. In the Chinese American Psychiatric Epidemiological Study, 6.4% of a random sample of 1,747 Chinese Americans living in Los Angeles were found to have neurasthenia, according to the ICD–10 (Zheng et al., 1997). Among them, the majority (56.3%) did not meet any current or lifetime DSM-defined mood or anxiety disorder diagnosis. In another study, Chang et al. (2005) found that 44.9% of Chinese patients with shenjing shuairuo did not meet the criteria for any DSM diagnosable disorders. Thus, shenjing shuairuo is a distinct clinical syndrome experienced by Chinese, rather than an alternative expression of any Western diagnosis. The phenom- enon of somatization is heterogeneous among Chi- nese, which can be a cultural syndrome in the form of shenjing shuairuo, a cultural idiom of distress contin- gent on the context in which they seek help and their cultural explanation of the symptoms they experience in response to their stress and sociocultural experi- ence (Mak, Cheung, & Leung, 2012).

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Finally, it must be emphasized that such report- ing of somatic symptoms was not specific to Chi- nese. Studies found no significant differences in the reporting of somatic systems across ethnic groups in general practice and that the reporting of somatic symptoms was very common among nonclinical populations across cultural groups (Simon, VonKorff, Piccinelli, Fullerton, & Ormel, 1999). Furthermore, the prevalence of somatiza- tion disorder was low among Chinese populations (1.5% in Shanghai, China) and was comparable to that among other Western populations (i.e., 1.7% in Seattle, Washington; 1.3% in Berlin, Germany; and 2.8% in Groningen, the Netherlands; Gureje, Simon, Ustün, & Goldberg, 1997). In a review of epidemiological studies examining the prevalence of somatization across different Asian regions or coun- tries (Mainland China, Taiwan, Hong Kong, Korea), the lifetime prevalence rates of somatization were very low (0–0.2%) and were comparable to that found among Asian Americans in the Epidemiologic Catchment Area Study (Chang, 2002).

This discussion of the Chinese somatization tendency illustrates how individuals’ beliefs, help- seeking behaviors, and symptom presentation, together with practitioners’ clinical and cultural sen- sitivity to these contexts, may affect their diagnostic classification. Likewise, the need for cultural sensi- tivity in psychological assessment in making clinical diagnosis and intervention decisions is evident. In the next section, we discuss issues related to cross- cultural validity of psychological assessment.

CROSS-CULTURAL PSYCHOLOGICAL ASSESSMENT

Psychological assessment forms a major part of the diagnostic process of psychopathology. The most common tools for clinical assessment include observation, interview, and testing. Psychological tests have become a standard method to evalu- ate psychopathology and responses to treatment. Among the psychological tests developed in the 20th century, standardized objective personality and cognitive tests with demonstrated reliability, valid- ity, and reference norms are the most commonly used tools in clinical assessment (Butcher, 2009).

Most of these tests were developed in the English language and assumed to be universally applicable. Many major clinical tests were translated and trans- ported to other language and cultural settings as though they were equivalent to the original tests. The translated tests were interpreted in the same way as though they were the original tests (Cheung, 2009). The universal assumption has been chal- lenged in cross-cultural assessment. Even when item translation is not involved, such as with projec- tive tests in which the test stimuli are not language based, cultural biases may arise from the assessment method itself as well as the uncertain cross-cultural validity of the imported tests (Church, 2001; Van de Vijver & Hambleton, 1996). With increasing cross-cultural interactions through globalization, migration, and population diversity, challenges of multicultural assessment are not limited to settings in which imported translated tests are used, but also when using same-language tests within geographi- cal boundaries with ethnocultural, gender, and class diversities (Van de Vijver & Poortinga, 1997). Cultural biases may result in misdiagnosis and mis- guided treatment decisions.

Cultural Biases and Cross-Cultural Equivalence in Psychological Assessment With the advances in international and cross- cultural psychology since the 1970s, there has been more focused discussion of the methodological issues in cross-cultural assessment (Cheung, 2009; Marsella, Dubanoski, Hamada, & Morse, 2000; Marsella & Leong, 1995; Van de Vijver & Leung, 1997; Van de Vijver & Poortinga, 1997). Marsella and Leong (1995) discussed two major ethnocen- tric errors in cross-cultural assessment. In the early stage of cross-cultural assessment, many research- ers directly applied the conclusions drawn from the original Western studies to represent universal human behaviors without conducting any cross-cul- tural comparisons, resulting in an error of omission. With this error of omission, it is assumed that there are no cultural variations in the observed results. Even when different cultural groups were included for comparison, the original Western measures were imposed on the other cultural groups as though they would be valid for all groups, resulting in an

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error of commission. Even when cultural variations are obtained, it is unclear whether the observed variations are substantive or the result of biases of imposed measurement.

Van de Vijver and Poortinga (1997) summarized three forms of bias in cross-cultural assessment: construct bias, method bias, and item bias. Construct bias refers to the variations or insufficient overlap in the definition of the construct being measured across cultures. The measurement of culture-bound syndromes would be illustrative. Culture-bound syndromes are generally limited to local cultures and may not have equivalent diagnostic categories in the DSM or ICD classification systems. So a mea- sure of these syndromes may not be meaningfully transported to another culture. Even with com- mon diagnostic categories, the inclusion or exclu- sion of specific behavioral manifestations may vary across cultures such that what are included in the measure may affect the definition of that construct. For example, not sitting still in a classroom may be considered hyperactivity for children in a dis- ciplined cultural environment, but it may not be considered as such for children in a freer and active environment.

Method bias refers to the procedure in the assess- ment that may give rise to cultural differences. The bias may arise from the nonequivalence in the back- ground of the cultural samples involved, which may affect their familiarity with the assessment method or the administration procedures. Cultural groups may differ in their response styles or social desirabil- ity tendencies toward the test stimuli.

Item bias may arise from nonequivalence between the original and the translated items, which may be due to inclusion of items that are irrelevant to the local culture, as well as translation errors or differ- ential item functioning, resulting in different item endorsement rates or different discriminatory power of the item across cultural groups.

Bias affects the comparability of test scores across cultures. To ascertain cross-cultural comparabil- ity, equivalence between the measures used for the different cultural groups has to be established. Researchers have discussed various forms of equiva- lence in cross-cultural research methodology (e.g., Van de Vijver & Leung, 1997; Van de Vijver &

Poortinga, 1997). Cheung (2009) summarized four levels of equivalence between the original measure and its adapted versions in personality assessment: linguistic equivalence, construct equivalence, psy- chometric equivalence, and psychological equiva- lence. Other authors may use different terms to describe these concepts.

Linguistic equivalence refers to equivalence at the basic level of item and instructions in which both language versions should convey the same literal meaning. Cross-cultural psychologists have recom- mended multiple translation methods to obtain accurate and appropriate translation.

Construct equivalence refers to the extent to which the psychological construct in the original culture is generalizable to the new culture. A personality construct may differ in form and level across cultures, and a literal translation may not capture the meaning of the underlying construct. So linguistic equivalence may not necessarily ensure construct equivalence.

Psychometric equivalence refers to the similarity in the psychometric properties of different language versions of the test. Differences in item endorsement rates, reliability, score level, and factor structure affect the confidence in whether the translated ver- sion can rely on the scientific evidence established for the original measure.

Psychological equivalence refers to the experien- tial familiarity, cultural relevance, or functional util- ity of the translated items or test in the target culture as demonstrated by the original test in the source culture. Demonstrating cross-cultural validity of the predictive functions of the translated test will sup- port the usefulness of the translated test in assessing similar diagnoses or predicting similar outcomes as intended by the original test.

A systematic approach to translation, adap- tation, and validation is particularly crucial in clinical assessment when tests from another cul- ture are adopted for diagnosis, treatment, and forensic evaluation (Cheung, 2009). Ensuring equivalence is an important part of the process of adapting tests to another culture. Recent advances in research methodology offer new statistical tools such as hierarchical multilevel analysis to compare cross-cultural similarities and differences at the

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individual level as well as at the multicultural level (van de Vijver & Leung, 2001). A good example of test translation and adaptation may be found in the international adaptation of the Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI–2 (Butcher et al., 2001).

Example of the Chinese Minnesota Multiphasic Personality Inventory The MMPI and MMPI–2 are the most widely used personality assessment tests in clinical settings in the world. More than 33 translations of the MMPI–2 are in use, and 22 language versions are currently available from the University of Minnesota Press (https://www.upress.umn.edu/test-division/ translations-permissions/available-translations). Butcher, Mosch, Tsai, and Nezami (2006) reminded practitioners about possible cultural influences on testing that may affect the accuracy of diagnosis and treatment, and they highlighted the cultural factors that should be considered when interpreting the MMPI–2 with clients from different cultural back- grounds (p. 510). In addition, Butcher and his asso- ciates (Butcher & Han, 1996; Butcher et al., 2006) have formulated a comprehensive system of cross- cultural adaptation of objective personality tests with technical solutions. The quality of international adaptations of the MMPI–2 should be evaluated against these parameters.

To achieve linguistic equivalence, Butcher, Lim, and Nezami (1998) advocated using multiple inde- pendent translators who are bilingual and bicultural to translate and back-translate the items. The pro- cess is repeated to reduce discrepancies to the mini- mum, paying attention to equivalence in vocabulary, idiom, and grammar.

To test for construct equivalence, Butcher and Clark (1979) recommended evaluating the bilingual test–retest reliabilities of both language versions taken by bilingual participants within 1 to 2 weeks and comparing these with the test–retest reliabilities of the single-language versions. Further validation studies should be conducted with monolingual par- ticipants in that culture.

A variety of statistical methods are used to pro- vide objective indices to demonstrate the psychomet- ric equivalence between different language versions,

including reliability, item-scale correlation, item endorsement frequencies, interitem correlations, interscale correlations, and factor congruence. The MMPI–2 Content Scales book (Butcher, Graham, Williams, & Ben-Porath, 1990) and MMPI–2 manual (Butcher et al., 2001) provide useful psychometric information on the English version to which the psy- chometric properties of the translated versions may be compared. By comparing the American norma- tive sample’s overall scores on the scale items with those of comparable samples in the target culture and determining whether responses to the items dif- fer widely, it can be established whether American norms can be appropriately applied or whether new set of local norms should be established through a restandardization study.

To determine psychological equivalence, empiri- cal studies are conducted to examine whether the pattern of test results with similar samples would predict outcomes similar to those of the original American studies. These local studies are needed to establish the cross-cultural validity of the inter- national versions of the MMPI–2 and confirm the usefulness of carefully adapted versions of MMPI–2 in clinical assessment when appropriate norms are used.

The Chinese translation of the MMPI–2 has fol- lowed closely these adaptation procedures. Cheung (2009) began the Chinese translation in the late 1970s in Hong Kong. Her Chinese version was introduced to the Institute of Psychology of the Chinese Academy of Science by the late Raymond Fowler, who led the first American Psychological Association (APA) delegation to visit the institute on its resumption of scientific activities after the end of the Cultural Revolution in 1980. The Chi- nese University of Hong Kong and the Institute of Psychology embarked on a long-term collaboration to translate and standardize the Chinese MMPI and then the MMPI–2. In addition to using bilingual translators and back-translators, Cheung and her team consulted with the original authors to capture the nuances of the language and the appropriate meaning of idioms in the English items (Cheung, 2009). They found that direct translation with accurate back-translation may not always capture the meaning of the emotional state highlighted in

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some English items, for example “I feel blue,” if they are literally translated. Particularly for idioms that are embedded in a particular culture, such as superstitious behavior, as in the item about being “careful to step over sidewalk cracks when walking,” literal translation of the item would not achieve psychological meaning or functional utility in the other culture. Similarly, interest in particular occupations or novels may not be experientially familiar to other cultures or shared across socio- cultural groups, reducing the functional utility of these items. In these cases, they have to be replaced with comparable items that are relevant to the local context. Empirical studies were conducted throughout the development and the refinement of the Chinese MMPI and MMPI–2 to establish their equivalence and cross-cultural validity. Large-scale standardization studies with representative sam- ples were conducted in China and Hong Kong to develop the Chinese norms. Clinical studies were undertaken to ascertain the usefulness of the Chi- nese MMPI and MMPI–2 in differentiating between psychiatric patients and the normative sample (Cheung & Song, 1989; Cheung, Zhao, & Wu, 1992). These studies are documented in the man- ual for the Chinese MMPI–2 (Cheung, Zhang, & Song, 2003).

The Chinese MMPI–2 is published by the Chinese University Press and the Institute of Psy- chology of the Chinese Academy of Science with permission from the University of Minnesota Press (https://www.chineseupress.com/mmpi). It is used by clinical psychologists for clinical and forensic assessment in Hong Kong, China, and Taiwan and by psychologists working with monolingual Chinese Americans in North America.

Development of Indigenously Derived Measures: The Example of the Chinese Personality Assessment Inventory and the Chinese Personality Assessment Inventory—2 The use of common psychological measures such as the MMPI–2 that have been properly adapted across cultures provides international research- ers and practitioners with valuable access to the research database supporting these measures’

clinical interpretation and facilitates cross-cultural comparisons of common psychological constructs. What may be amiss in adopting imported tests, however, is that understanding of the local con- ceptualization of personality constructs may be submerged when an etic structure is imposed on the local context. The constellation of personal- ity facets in complex constructs and the behavioral manifestation of these constructs may vary across cultures. For example, “just sitting and doing noth- ing,” which may be a sign of depression in the more action-oriented American culture, would be consid- ered a form of desirable relaxation in the Chinese context. Comparing endorsement frequency and social desirability of this item between normal col- lege samples in the United States and Hong Kong confirmed the discrepancy in the psychological equivalence of this item. Similarly, refraining from asserting confidence about one’s achievements may be expected in conformance with the Confucian value of modesty. Inclusion of many items of this nature would increase the scale score on depression for normal Chinese respondents when in fact they are not depressed. Alternatively, studies on Chinese psychopathology have shown that patients tend to present their depression in somatic symptoms, such as lost appetite, sleep problems, and fatigue (Cheung, 1998). Should some of the irrelevant items be replaced by more culture-specific items? Going further, would an indigenously derived measure more accurately capture the local illness experi- ence and identify gaps in understanding important culture-specific personality factors contributing to psychopathology?

Development of indigenous measures requires the same scientific rigor as in all assessment mea- sures. In non-Western cultures in which the profes- sion of psychology is still emerging, the expertise and resources required for such endeavors may be inadequate. The early attempts to develop indig- enous personality measures in Asia adopted an indigenization-from-without approach (Enriquez, 1993) by translating and adapting items from familiar Western instruments and then adding indigenous items or subscales (Cheung, Cheung, Wada, & Zhang, 2003). With the growth of indig- enous psychology, there is a stronger emphasis on

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the indigenization-from-within approach (Enriquez, 1993) to develop theories, methods, and measures using emic concepts and knowledge from within the local context.

Cheung, Fan, and Cheung (2017) reviewed some of the Asian indigenous personality measures and identified limitations in adopting an entirely indige- nous approach. In addition to the shortfall in theory and scope of the research framework supporting the applications of these early measures, the focus on only culture-unique constructs restricts understand- ing of personality from a pan-cultural perspective. The combined emic–etic approach was advocated as an alternative paradigm for deriving culturally relevant measures, citing the example of the Chinese Personality Assessment Inventory (CPAI; Cheung, Cheung, Zhang, et al., 2008; Cheung et al., 1996).

The CPAI was developed by the research team from the Chinese University of Hong Kong and the Institute of Psychology at the Chinese Academy of Science who worked on translation and standard- ization of the Chinese MMPI–2. The research team adopted an empirical approach to identify cultur- ally relevant Chinese personality constructs from person descriptions in everyday life using multiple sources and generated items on the behavioral mani- festations of these constructs. Large samples of the general population were tested to select items and finalize scales on the basis of their psychometric properties. The CPAI and its revised version, the CPAI–2, were standardized using representative normative samples from different parts of China and Hong Kong. The CPAI–2 consists of 28 normal per- sonality scales, 12 clinical scales, and three validity scales. Four factors were extracted from the normal personality scales: Social Potency, Dependability, Accommodation, and Interpersonal Relatedness. Two factors, Emotional Problems and Behavioral Problems, were extracted from the clinical scales. A more detailed description of the CPAI may be found in Cheung, Fan, and Cheung (2013).

An extensive research program was conducted to validate the CPAI. The CPAI was compared with the Chinese MMPI–2 to establish its concurrent validity (Cheung, Cheung, & Zhang, 2004). The CPAI clinical scales were highly correlated with the corresponding clinical and content scales of the

MMPI–2. Studies with large samples of psychiatric patients were conducted to validate the clinical util- ity of the CPAI and CPAI–2 (Cheung, 2007; Cheung, Cheung, & Leung, 2008; Cheung, Gan, & Lo, 2005; Cheung, Kwong, & Zhang, 2003). These studies showed that the clinical scales discriminated among different psychiatric diagnostic groups. The normal personality scales also supplement the clinical pro- files by presenting long- standing personality dynam- ics and defense mechanisms with implications for psychological treatment.

With the combined emic–etic approach, it is pos- sible to evaluate the incremental validity of indig- enous constructs in understanding psychopathology and predicting outcomes. A joint factor analysis of the CPAI–2 and the NEO Five Factor Inventory (Costa & McCrae, 1992), a measure of the five-factor model, which has been regarded as a universal factor structure, found that three of the normal personal- ity factors overlap with the Big Five (Social Potency with Extraversion and Openness, Dependability with Neuroticism and Conscientiousness, Accommoda- tion with Agreeableness). An indigenous personality factor, Interpersonal Relatedness, was identified as being independent of the existing universal personal- ity structure subsumed under the five-factor model (Cheung, Cheung, Zhang, et al., 2008). In addition to the Dependability factor scales (such as Emotionality, Inferiority vs. Self-Acceptance) that were associated with clinical features, the emic scales also provided useful cultural perspectives in understanding psycho- pathology in the Chinese context.

For example, high scores on Face and Harmony, two of the emic scales on the Dependability factor and the Interpersonal Relatedness factor, respec- tively, predicted the clinical Somatization scale. The tendency to avoid shame and disruptions in social harmony may explain the Chinese inclination to present stigmatized mental problems in the form of somatic complaints. Lower scores among psychiatric patients on other emic scales included in the univer- sal personality factors, such as Family Orientation on the Dependability factor, showed the breakdown in family support among these Chinese patients, given the family plays a central role in Chinese culture (Cheung, Cheung, & Leung, 2008). Low scores on the Harmony, Renqing (reciprocal social

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exchange), and Family Orientation scales and high scores on the Face scale reflect risks in social mal- adjustment that form an important consideration of normality in collectivistic cultures. These emic dimensions are not intended to replace the well- tested universal dimensions of personality but can provide important cultural perspectives to supple- ment understanding of psychopathology beyond the universal dimensions.

International Best Practices Practitioners and researchers in cross-cultural assessment need to decide how they should choose the most appropriate assessment tools. If they adopt translated versions of existing measures, they should evaluate how well the measures have been translated and adapted. Since the 1980s, psycholo- gists engaged in assessment and national profes- sional associations have raised attention about the need for standards in test translation and adaptation (Geisinger, 1994). For example, the Standards for Educational and Psychological Testing (American Educational Research Association, APA, & National Council on Measurement in Education, 1985) included a chapter that outlined standards for test- ing individuals who are linguistic minorities. The call for a common set of international guidelines for cross-cultural assessment culminated in the col- laboration among international psychological asso- ciations and international psychologists to prepare guidelines for translating and adapting psychologi- cal instruments and to establish score equivalence across language and cultural groups The Interna- tional Test Commission (ITC) published its pre- liminary set of guidelines in 1996 and conducted field testing to evaluate their applications. These guidelines were formally adopted by ITC in 2005 and distributed to national psychological societies, test publishers, and researchers. Van de Vijver and Hambleton (1996) elaborated on how the guide- lines can be applied. The 22 guidelines cover four domains:

1. Context guidelines describe the basic principles of multilingual measurement in which cultural bias should be identified and assessed before test translation and adaptation are undertaken.

2. Guidelines on instrument development consist of recommended practices in the translation process and evaluation to ensure appropriate translation and adaptation when developing multilingual instruments.

3. Administration guidelines address issues in administering the instrument in a new cultural context.

4. Documentation and score interpretation guide- lines recommend that test translators maintain careful documentation of changes made and observed intergroup differences that may affect the interpretation and cross-cultural compari- sons of scores.

With the expanding domain of testing in multicultural groups, ITC (2016) further updated the guidelines in a second edition, incorporating new methodology and technological advances for test adaptation and adding requirements on observing intellectual property rights of published tests. The revision includes 18 guidelines grouped under six categories: precondition, test devel- opment, confirmation, administration, scoring and interpretation, and documentation. Clearer explana- tions on the rationale and suggested practice for each guideline are included.

The extensive efforts in developing and promot- ing international guidelines on test adaptation point to the importance of ensuring fairness and accu- racy in cross-cultural assessment. Unfortunately, many practitioners and researchers have adopted tests across cultures without paying attention to these guidelines. It should be further emphasized that testing across cultures is not simply a mat- ter of test translation and adaptation from one culture to another. Should an indigenous test be used? How should indigenous measures be evalu- ated? It involves a deliberate consideration to select the approach best suited for the purpose of the assessment.

Using Church’s (2001, p. 984) classification, the level of indigenization ranges from “imposed etic” (tests are adopted in non-native languages or are translated literally) through indigenization from without (items are modified, local norms are collected, or new items are generated to fit the imported constructs) to indigenization from within

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(local constructs are identified and measures to assess them are investigated to establish their reli- ability, validity, and utility according to indigenous criteria). Church raised several pertinent questions in addressing the issue of choosing imported versus indigenous measures: “How well do the dimensions and their behavioral exemplars in imported mea- sures replicate in the local culture?” “Can imported measures predict relevant criteria in the local cul- ture?” “Are the indigenous measures and their constructs indeed culture-specific?” and “Do these indigenous measures contribute incremental valid- ity beyond that of existing imported measures?” (pp. 986–987). Researchers and practitioners should familiarize themselves with the measures under con- sideration, evaluate their psychometric properties, and balance the need for cross-cultural comparison against the need for culturally relevant assessment (Cheung et al., 2017).

Given the importance of cross-cultural and intersectional considerations in understanding individuals’ illness experience, the diagnosis of psy- chopathologies, and the assessment of culturally diverse populations, in the next section we review how psychology departments and psychology gradu- ate training programs have adopted multicultural and social justice perspectives in their training and the ways forward in preparing the profession for an international mental health agenda.

MULTICULTURAL PERSPECTIVES IN CLINICAL AND COUNSELING PSYCHOLOGY CURRICULUM AND TRAINING

Decades have passed since the initial assertion was made by D. W. Sue and his colleagues that cross- cultural competence is essential for the practice of counseling psychologists (D. W. Sue et al., 1982); APA has issued various guidelines on psychological practice for ethnic, linguistic, and culturally diverse populations (APA, 1993), older adults (APA, 2004, 2014), and lesbian, gay, and bisexual individuals (APA, 2012; Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000). APA launched guidelines

on multicultural education, training, research, prac- tice, and organizational change in 2003 and passed a resolution on culture and gender awareness in inter- national psychology in 2010. In addition, it has set up a joint Division 52 (International Psychology)/ Division 5 (Evaluation, Measurement, & Statistics) Task Force to identify updates for the methodologi- cal aspects of cross-cultural research and pinpoint the need for training in cross-cultural methodol- ogy in research and assessment (Byrne et al., 2009). Researchers and practitioners in cross-cultural assessment need to familiarize themselves with international best practices and the research base of translated versions of standard psychological tests. Furthermore, psychologists need to be trained in multicultural competence and social justice to effec- tively serve culturally diverse populations.

Need for Cross-Cultural Perspectives in Training Since the 1960s, researchers and practitioners have advocated for cross-cultural considerations in the delivery of mental health services and counseling practices. Many have lamented the lack of atten- tion to culturally diverse populations and the biased claims made against certain ethnic groups as either genetically deficient or culturally deprived as explaining the observed negative outcomes (e.g., genetic deficient model, culturally deficient model), neglecting the prevailing social oppression in society (D. W. Sue et al., 1982). Training and practice in psychology assumed an etic or Eurocentric perspec- tive, which places cultural concerns at the periph- ery, with little regard to how people’s personal, professional, and societal value systems affect the way researchers and practitioners understand and interpret psychological and social phenomena. In response to these biased assumptions and stereotyp- ing, D. W. Sue et al. issued a position paper in 1982 defining cross-cultural counseling and therapy and cross-cultural competencies.

Tripartite Model: A Theoretical Framework for Culturally Competent Counseling According to D. W. Sue, Arredondo, and McDavis (1992), “Cross-cultural counseling/therapy may be

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defined as any counseling relationship in which two or more of the participants differ with respect to cultural background, values, and lifestyle” (p. 47). They also delineated the tripartite model of beliefs–attitudes, knowledge, and skills in the devel- opment of a culturally competent counseling psy- chologist. In this model, beliefs–attitudes are defined as being aware of and valuing cultural differences between therapists and their clients. Therapists are aware of how their own values and biases may affect their effectiveness with their clients, and they actively seek consultation and supervision and pro- vide referral to a more culturally competent thera- pist as necessary.

Regarding knowledge, therapists should acquire knowledge specific to the cultural groups with whom they work, including their history, cultural values, and lifestyles. Moreover, therapists should be cognizant of the various levels of oppression and dis- crimination that affect cultural groups’ identity and worldviews and the access to and quality of services received by different cultural groups in the service systems and in the community. Therapists should also be aware of possible biases and limitations in their professional training and knowledge with respect to the treatment of culturally diverse groups.

Finally, skills refers to adopting a broad repertoire of nonverbal and verbal responses to appropriately communicate with culturally diverse clients. Thera- pists should not be confined to the intrapsychic model and traditional one-to-one office-based coun- seling but be ready to outreach and expand their roles as social change agent and ombudsman outside of the counseling room in the clients’ natural setting and indigenous culture (D. W. Sue et al., 1982).

Since D. W. Sue et al.’s (1982) seminal article, the tripartite model has commonly been adopted as the standard in training, particularly within the counseling psychology profession. Pedersen (2000) adopted the tripartite model in cross-counseling training during which a problem or anticounselor role is added to role-play sessions to highlight the neglected or subconscious cultural dimensions that interfere with the communication between the counselor and the client. D. W. Sue et al. (1992) further expanded and detailed the tripartite model to recognize the intersectionality of various

sociocultural factors and sociopolitical contexts on a particular client, including immigration status, poverty, and racism. The model was later adopted by the APA when it issued the Guidelines on Mul- ticultural Education, Training, Research, Practice, and Organizational Change for Psychologists in 2003. Despite its comprehensiveness in addressing the importance of multiculturalism across domains in teaching, training, research, practice, and organi- zational change, the guidelines remain aspirational.

To operationalize multicultural competence for research and practice, scholars have tried to delineate the essential elements in cultural com- petency. S. Sue and Zane (1987) proposed the proximal–distal model to explain cultural difference. Rather than resorting to simply explaining group differences as the result of racial or ethnic differ- ences, they proposed identifying proximal factors such as therapist or client attitudes in explaining the observed outcomes. S. Sue (1998) also proposed the importance of having scientific mindedness (forming and testing hypotheses about the status of culturally diverse clients rather than making assumptions and drawing premature conclusions), dynamic sizing (being flexible in knowing when to generalize or individualize according to the specific context), and culture-specific skills (being able to translate interventions into culturally appropriate strategies) in the process of working with cultur- ally diverse clients. Besides these general processes, S. Sue (1998) also proposed specific concrete steps that therapists can take to improve their cultural competency, including self-awareness and aware- ness of their own stimulus value, assessment of clients, pretherapy intervention, hypothesizing and testing specific hypotheses, credibility and giving, understanding discomfort and resistance, under- standing clients’ perspective, intervention planning and strategy, session assessment, and willingness to consult. All of these efforts aim to clarify and operationalize what it takes to become culturally competent.

In addition to elaborating on the conceptualiza- tions of cultural competence, research was in place to demonstrate its significance to client outcomes. For example, among a multiethnic sample of cli- ents served by a community mental health agency

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in San Francisco, ethnic match was predictive of session comfort, positivity, and arousal, and cogni- tive match was predictive of session depth. As to treatment outcomes, cognitive match on avoidant coping and on problem distress between therapist and client was predictive of more favorable out- comes on psychological symptoms and functioning (Zane et al., 2005). Rather than being limited to the provider–client level, multicultural compe- tence needs to be achieved at the agency level as well. In other words, cultural diversity should be considered in the hiring, organizational structure, program development and evaluation, outreach, access, availability, utilization, and quality of ser- vices to ensure that the agency is effective in serving a culturally diverse clientele. More broadly speak- ing, the systems of care need to be multiculturally competent through collaboration across service agencies in the community and with various institu- tions in the community (e.g., schools, churches, law enforcement) to provide equitable and culturally appropriate services (S. Sue, 2006). These elements of multicultural competence across levels of inter- ventions and diverse cultural groups were mapped onto the multidimensional model of cultural com- petence by D. W. Sue (2001).

Despite all these efforts, multicultural compe- tence training has still fallen short in actual prac- tice. An earlier study showed that about one third of clinical and counseling psychology graduates had received training in serving culturally diverse populations (Allison, Crawford, Echemendia, Rob- inson, & Knepp, 1994). Moreover, compared with counseling psychology training programs, signifi- cantly fewer clinical psychology training programs required a multicultural competence course for their students (Mintz, Bartels, & Rideout, 1995), and counseling psychology students reported a higher level of multicultural competence than clinical psychology students (Pope-Davis, Reyn- olds, Dings, & Nielson, 1995). Although the APA requires all accredited doctoral clinical and counsel- ing psychology training programs to include courses covering multicultural issues, only 67.6% of the APA- accredited programs have made a multicul- tural competence course a mandatory requirement (Sherry, Whilde, & Patton, 2005).

Research has also found that compared with psychologists who are experienced in multicultural counseling, clinical psychology students have a sig- nificantly lower level of multicultural competence, endorsement of multiculturally competent strate- gies, and actual engagement in such multiculturally competent practices (Sehgal et al., 2011). Despite inconsistent training in and practice of multicultural competence, a meta-analysis of 45 retrospective sur- vey studies showed that individuals who reported completing multicultural education had a weighted average effect size of 0.49 on multicultural counsel- ing competence measures compared with those who did not (Smith, Constantine, Dunn, Dinehart, & Montoya, 2006). Another meta-analysis based on 37 studies that evaluated an actual multicultural educa- tion intervention demonstrated an average effect size of 0.92 before and after the training. Specifically, education that was explicitly based on extant theory showed a significantly larger effect size (d = 1.13) than education that was not theoretically based (d = 0.61; Smith et al., 2006). These findings point to the effect of multicultural education and the need for more consistent training in multicultural compe- tence across all clinical and counseling psychology training programs.

In addition to advocating for training in mul- ticultural competence, the format in which such training should be delivered and the scope such training should cover have also been much debated and discussed. Going beyond the one-course prac- tice in offering only one didactic course in the entire course of clinical and counseling psychology train- ing, scholars have recommended that multicultural issues should be integrated throughout the curricu- lum across courses in assessment, psychotherapy, practice, and supervision with the infusion approach (Abreu, Chung, & Atkinson, 2000). In addition, rather than using such traditional pedagogical strategies as lectures and readings, students should be involved in participatory methods, including simulations and role-plays, and have opportunities to be immersed in culturally diverse communities and provide services to culturally diverse popula- tions with culturally competent supervision to translate their knowledge into actual practice and to foster their multicultural attitudes and mindset

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(Dickson & Shumway, 2011). Borrowing from the gender mainstreaming concept, Cheung (2012) recommended “regular cultural analysis and audits . . . to review the extent to which cultural consider- ation is incorporated in the research and practice of psychology. This culture-grounded knowledge base should constitute an integral component of basic training in psychology” (p. 728).

Social Justice Training Beyond multicultural competence as captured by the tripartite model of knowledge, awareness, and skills, a focus on social justice advocacy and leadership has been emphasized, especially in community psychol- ogy and counseling psychology training (Kumagai & Lypson, 2009; Vera & Speight, 2003). Social justice training focuses on raising the critical consciousness of psychology students in recognizing the oppression that limits access and opportunities in society because of one’s sociocultural characteristics (i.e., race/ethnic- ity, gender, class, sexual orientation, age, education, ability, religion). It emphasizes the importance of rais- ing individuals’ critical reflection on societal inequali- ties, enhancing their political efficacy to initiate and participate in social change and collective action, and encouraging them to take critical action to effect change in institutional policies and practices that per- petuate injustice (Watts, Diemer, & Voight, 2011).

A review of 47 texts and 54 syllabi of multicul- tural and diversity-related courses in counseling psychology showed that although 96% of the syllabi incorporated some aspects of knowledge aware- ness and skills from the tripartite model, 59% of the goal statements and objectives mentioned social justice and 48% included social justice concepts (Pieterse, Evans, Risner-Butner, Collins, & Mason, 2009). With this social justice perspective, clini- cal and counseling psychologists no longer relegate their roles to understanding and facilitating changes to clients’ presenting issues; they can also become advocates for clients’ rights within and beyond the service system, enable self-advocacy by their clients and families, and act as change agents in the society to level injustices and social inequalities that con- tinually oppress disadvantaged groups (Constantine, Hage, Kindaichi, & Bryant, 2007). Social justice training can also broaden clinical, counseling, and

community psychology students’ appreciation of the social oppression is going on internationally, facilitating the improvement of global mental health and setting mental health as a global agenda. These directions echo with the World Health Organiza- tion’s (2013) Mental Health Action Plan 2013–2020, which emphasizes a human rights approach to mental health and empowerment of individuals with mental disorders in advocacy, policy, legislation, service provision, monitoring, research, and evalu- ation, among other strategies to eradicate mental health disparities globally.

CONCLUSION

Culture is in the fabric of human experience. In understanding assessment, diagnosis, and treatment of psychopathology, the intersectionality of vari- ous sociocultural factors and sociopolitical contexts must be carefully considered to effectively facilitate clients’ change and growth. As such, solid and inte- grated multicultural competence training must be implemented throughout the curriculum of clinical, counseling, and community psychology training to effect changes in research and practice. Moreover, going beyond the individual level, psychologists should recognize and engage in multicultural com- petence and social justice strategies at the organiza- tional, service systems, and community and societal levels to avert social oppression and promote human rights to mental health for all individuals. These efforts are imperative in actualizing the international agenda of global mental health.

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