Teaching Culturally Informed Psychological Assessment: Conceptual Issues and Demonstrations

Transcription

1 JOURNAL OF PERSONALITY ASSESSMENT, 79(2), Copyright 2002, Lawrence Erlbaum Associates, Inc. Teaching Culturally Informed Psychological Assessment: Conceptual Issues and Demonstrations Steven Regeser López Department of Psychology University of California, Los Angeles Multicultural assessment requires a strong conceptual foundation to address the complex and dynamic nature of culture. I present 3 conceptual issues as well as the demonstrations or exercises that I use to teach these concepts to students in a doctoral program of clinical psychology. The first conceptual issue is that multicultural assessment requires a solid foundation in traditional assessment theory and methods. Second, culturally informed assessors specify and test what about the social and cultural world matters to avoid making inferences based on group labels associated with ethnicity or race. Third, culturally responsive assessors must formulate and test both culture-specific and alternative (impairment or dysfunction) hypotheses, which refers to shifting cultural lenses (Kleinman & Kleinman, 1991). I then review exercises and demonstrations to illustrate these conceptual ideas. My aim is to help instructors guide students of assessment toward integrating a process-oriented way of thinking about culture, one that promotes a critical approach to our understanding of the role of culture in human behavior and its assessment. A strong conceptual foundation is needed to advance multicultural assessment. Culture is a complex, dynamic phenomenon that is grounded in social and historical contexts (Jenkins & Karno, 1992; López & Guarnaccia, 2000). Therefore, assessment approaches must be respectful of the complex and dynamic nature of culture. I am one of three instructors of a first-year general assessment course for doctoral students in clinical psychology. My main responsibility is to address issues of culture, race, and ethnicity. I spend a significant proportion of my sections on conceptual matters. Over the years I have developed exercises and illustrations to help students understand some of the complexity regarding cultural matters. In

2 TEACHING CULTURALLY INFORMED ASSESSMENT 227 this article, I present some of the key conceptual issues regarding culture that I raise in my class as well as the demonstrations that I use to explain or illustrate these points. My aim in this article is to help instructors guide students of assessment toward integrating a process-oriented way of thinking about culture. CONCEPTUAL GROUNDING IN ASSESSMENT A solid foundation in general assessment principles and methods is necessary for students to develop expertise in multicultural assessment. My colleagues 1 assist me greatly in this domain by covering key principles of assessment including hypothetical constructs and intervening variables (MacCorquodale & Meehl, 1948), construct validation and nomological nets (Cronbach and Meehl, 1955), convergent and discriminant validation (Campbell & Fiske, 1959), clinical and statistical prediction (Meehl, 1954), ecological systems theory (Brofenbrenner, 1989), consequential validity (Messick, 1980), and moderation/mediation (Baron & Kenny, 1986). Whenever possible, I then try to tie these and other key principles to assessment issues as they pertain to culture. For example, in our class session concerning culture, race, and ethnicity, I draw on the students knowledge of construct validation. Specifically, I encourage them to evaluate the network of associations tied to racial or cultural explanations for specific psychological phenomena (Clark, 1987; Zuckerman, 1990) to help them discern when there is sufficient and insufficient evidence to support racial or cultural explanations. There are many advantages to bringing existing theory and methods in traditional assessment to bear on multicultural assessment issues. Most important, students interested in culture will have a solid foundation from which to build their developing multicultural expertise. For those less interested in culture, they will learn that this domain is a legitimate area of inquiry for psychological science. In all, tying multicultural issues within the framework of traditional assessment serves to enhance the necessary dialogue between both areas of assessment (see also Clark, 1987). An underlying tension that arises early in the discussion of multicultural and traditional assessment concerns assumptions regarding the group specificity or universality of human behavior. Some students believe culture plays a prominent role in understanding human behavior, whereas others believe that culture plays a less significant role in explaining human behavior. The former position suggests that group-specific instruments are necessary to assess given constructs among culturally diverse groups, whereas the latter position suggests that mainstream instruments are sufficient to assess given constructs across groups. 1 I am privileged to share the teaching of assessment with my colleagues Tom Bradbury and Rena Repetti.

3 228 LÓPEZ To address this tension, I engage students in the following exercise. I show them a slide with the continuum: universal culture specific. I then ask them to rate the extent to which human behavior is culture specific, from 0% to 100%. I tell them that if they believe human behavior is universal, then they would make a rating of 0% culture specific. On the other hand, if they view human behavior as having distinct meanings for specific groups, then they would make a rating of 100% culture specific. After the description of the poles, I then ask them to make a rating that falls anywhere on the 0% and 100% culture-specific continuum. Following their ratings, I then ask the students to raise their hands indicating in which quartile (0% to 25%, 26% to 50%, 51% to 75%, or 76% to 100%) their rating falls. In addition, I select one or two representatives of each quartile to explain briefly why they made their ratings. Typically there is considerable variability in students ratings. The main point of this exercise is to indicate that those who view behavior as largely culture specific are at risk to overlook the universality of behavior, whereas those who view behavior as largely universal are at risk to overlook the culture specificity of behavior. For example, if a patient who is American Indian presents with a belief that the spirit of a deceased relative visits her, then the person who views behavior as largely universal may overlook the possibility that this may be a culturally normative belief and not reflective of delusional thinking. In contrast, the person who views behavior as largely culture specific may overlook the possibility that this false belief is indeed delusional in nature. I argue that there should be a healthy tension between viewing behavior as culture specific and culture general. This does not imply that any given behavior is either largely culture specific or universal. It may be that behavior is both culture specific and universal, depending on the observer s level of analysis (Shweder & Bourne, 1984). The main purpose of this exercise is to help students recognize their potential bias in considering the role of culture in understanding human behavior and its assessment. CRITICAL THINKING A key theme of our course is How do we know what we know? My colleagues and I want our students to be critical consumers of assessment data in both clinical and research contexts. I present two main conceptual points throughout the course to help students think critically about culturally related topics. First, I strongly encourage students to go beyond or unpack the molar concept of culture by hypothesizing what about culture matters (Betancourt & López, 1993; López, 1994). This enables them to test specific cultural hypotheses rather than applying a general cultural gloss that purportedly reflects traditional culture or a group s culture (e.g., Black culture). I then push students to identify what they think are the specific aspects of the sociocultural world related to the observed phenomena, such as spirituality, family closeness, or experiences of discrimination. Accordingly, I then

4 TEACHING CULTURALLY INFORMED ASSESSMENT 229 encourage students to assess directly whether those specific factors play a role in their client s functioning. The important point is for assessors to specify and test what about the social and cultural world matters and to avoid making inferences based on group labels associated with ethnicity or race. The second component of the critical thinking approach that I present to students is the importance of generating and testing alternative hypotheses. It is not enough to formulate and test culture-specific hypotheses. Assessors must also test alternative hypotheses. Typically these are the hypotheses that the client or family has some impairment or dysfunction. The importance of assessing alternative hypotheses in the context of culturally informed assessment is to remind the assessor that even if there is evidence to support culture-specific formulations (e.g., the client and family adhere to specific cultural beliefs regarding spirituality), there may also exist evidence of impairment (the patient has delusions of a spiritual nature that contribute to impairments in social functioning). Psychosis can be expressed in auditory hallucinations of deceased relatives and religious figures even among individuals with a strong spiritual background. Enmeshment can exist in families who value close, intimate ties. Evidence of culture-specific factors and alternative (psychopathology) factors are needed to make these fine distinctions. To avoid attributing a client s functioning to solely sociocultural factors with the accompanying risk of minimizing or overlooking actual pathology, assessors must formulate and test both culture-specific and alternative hypotheses (López et al., 1989). I refer to this two-pronged critical thinking approach as shifting cultural lenses, a concept I borrowed from Kleinman and Kleinman (1991). They argued that the clinician (and researcher) should move between lay systems of meaning and professional systems of meaning to make sense of behavioral observations. In other words, the clinician should shift between the client s specific cultural set of meanings and the clinician s own set of meanings. By entertaining specific cultural hypotheses (e.g., spirituality) and alternative hypotheses (e.g., delusions), one is shifting cultural lenses from the possible lenses of the client to the lenses of the professional. I have found that the idea of shifting cultural lenses to be a most useful heuristic in teaching students how to incorporate both a healthy appreciation of possible cultural meanings and a critical approach to the role of culture. I have developed two exercises to communicate this two-pronged approach to critical thinking in culturally informed assessment. In the first demonstration students are encouraged to move beyond a cultural gloss and develop specific cultural hypotheses. This is carried out in an exercise of clinical judgment. I set up the experience so that students learn the possible risks in attributing a patient s behavior to his or her cultural background based solely on the patient s ethnic background. This exercise combines a brief lecture, students observation of a client in an enacted interview, students evaluation of the clients presenting problems, group discussion, and another brief lecture.

5 230 LÓPEZ At the beginning of the demonstration, I present a one-sided minilecture of the role of culture and psychopathology. I argue that culture has largely been ignored in the study of psychopathology and that it plays a most important role. (This is a one-sided view because I do not point out the evidence that mental illness is universal; Murphy, 1976.) I then refer to two excellent examples of how culture is related to psychopathology. The first concerns how culture can influence the expression of mania among Amish bipolar patients (Egeland, Hostetter, & Eshleman, 1983) and the second addresses how culture is related to the expression of internalizing and externalizing disorders in children (Weisz, 1989). My main point is that culture matters. My intention is to prime the students view of how important culture is to increase the likelihood that they implicate culture in their judgments of the case that is to follow. I then provide a brief background of the client, Mrs. Ramirez, to the students. I describe her as a 26-year-old married Mexican immigrant living in Los Angeles with no children. Following the introduction, I present a videotape of an enacted clinical interview that lasts about 12 min. Joseph Nuñez, a former student, and I developed the videotaped interview for research purposes some years ago. The presenting problems were based on problems of actual patients. In responding to the clinician s questions, Mrs. Ramirez presents multiple problems including physical problems (numbness in the jaw), problems with her marriage (her husband sometimes leaves and does not return until the next day), and depressive symptoms (loss of interest in usual activities). Following the videotape, I instruct students to make two sets of clinical judgments regarding the severity of the client s problems (e.g., marital adjustment, depression, somatization, and likelihood of having a physical problem), the likelihood of benefitting from therapy, and their degree of interest in wanting to serve as her therapist. For the first set of ratings, I instruct them to assume that the presenting problems are related to the patient s (Mexican) cultural background. On completing those ratings, I then ask them to rate the client again this time assuming that her presenting problems had nothing at all to do with her cultural background. Through the instructional sets, I attempt to manipulate the students attributions of the presenting problems to the client s cultural background. After they complete their ratings, we then discuss whether their judgments were influenced by taking culture into account or failing to take culture into account. Invariably some students volunteer that their ratings changed. For example, a student might say that when she took culture into account she viewed the patient as suffering from less marital distress. I then encourage the student to articulate the basis for her change in rating. Students are pretty good at generating specific hypothesis such as, in this case, the husband s involvement in extramarital relationships may be more acceptable for women of Mexican origin. On further inquiry, the student might make some reference to machismo or traditional marital roles. Another student might comment that when he believed culture played a significant role he

6 TEACHING CULTURALLY INFORMED ASSESSMENT 231 thought Mrs. Ramirez would be less likely to suffer from an actual physical disorder. He might refer to the notion that Latinas may tend to express psychological distress as physical distress, a cultural notion he had read about. Many students seem to feel comfortable in sharing their ratings and discussing the possible specific cultural factor that might be playing a role. Not all students have different ratings across the two conditions and for some students it is hard to come up with specific cultural formulations. After time is allotted for discussing the students impressions, I then turn to relevant literature concerning the cultural basis of presenting problems of Latinos. I refer to the literature on traditional marital roles (Cromwell & Ruiz, 1979) and somatization (Escobar, Burnam, Karno, Forsythe, & Golding, 1987). I argue that the best available data does not support the view that Mexican Americans adhere to machismo and traditional marital roles and that somatization is not as prominent among Mexican Americans as some clinical writings suggest. I point out that there is little empirical support for many of the cultural notions that clinicians might have for Mexican-origin patients. Furthermore, I argue that Mexican-origin people are quite heterogeneous in terms of their cultural beliefs, norms, and practices. Finally, I then caution them that imposing their notions of what is culture and what is not culture based strictly on ethnicity can be detrimental to their clients. Clinicians may then tend to minimize or underpathologize actual problems and distress (López, 1989; López & Hernandez, 1986). Having a husband who is involved in extramarital relationships, for example, can be most distressing to many Mexican women and may not at all be part of their cultural world. Assuming that men s extramarital relations are culturally acceptable behavior is strictly an assumption. I acknowledge the artificial nature of this exercise. A clinician is never asked to make cultural attributions and then asked to reconsider the case without considering the role of culture. Furthermore, I let them know that I tried to elicit their cultural attributions. Nevertheless, despite the artificiality of the exercise, what makes it most useful is that the students actually consider how they conceptualize culture (general or specific) in a given clinical context. Moreover, they observe first hand how their cultural considerations or that of their peers can affect their clinical judgment. The experiential aspect contributes to making concrete the concept of cultural gloss and culturally specific hypothesis testing. To carry out this exercise, instructors could choose their own clinical case or draw one from pertinent clinical writings. The point is to select a case or cases that pull for cultural stereotypes, ideally ones for which there is research to suggest that the stereotypes are true or false. For the second exercise, I illustrate the concept of shifting cultural lenses. I draw from one of my many lessons in driving the highways of Mexico. The lesson is straightforward turn signals have multiple meanings. In Mexico, the public highways typically have only two lanes, one each for opposing traffic. The advan-

7 232 LÓPEZ tage of the public highways is that there is no fee and the disadvantage is that with a slow moving vehicle and no passing lanes, traffic can accumulate quickly. Drivers who do not want to be delayed cross over to the opposing lane when possible. In the event that there is no oncoming traffic they accelerate to pass the slower vehicle. This can be quite dangerous, as the visibility of the driver intending to pass is oftentimes blocked by the vehicle in front of him or her or by the lay out of the road (e.g., hills or curves). To assist in passing each other safely, Mexican drivers, particularly professional drivers, have developed a simple but effective form of signaling motorists who wish to pass. When there is oncoming traffic, the driver in front turns on the right-hand turn signal; the intended message is Don t pass, cars are approaching. When the same driver sees that there is no oncoming traffic, he signals to the motorist waiting to pass by turning on the left-hand turn signal. This means that no cars are approaching and that the driver can pass safely. Interestingly, some trucks and other large vehicles have rear mud flaps with the words SIGA and ALTO. SIGA, which means to continue, is placed below the left-hand turn signal, and ALTO, which means to stop, is placed below the right-hand turn signal. These mud flaps reflect the alternative meanings. The other possible meaning of the turn signal is, like in the United States, to indicate an upcoming turn. The challenge for the driver behind a slow moving vehicle then is to figure out the intended meaning of the turn signal. I present this contextual background with a series of slides of backed-up traffic on the public freeways and of mud flaps with SIGA and ALTO. I then present a slide of a truck with a blinking left turn signal and ask the students how they might know which set of meanings to apply the usual meanings associated with turning or the other meanings regarding oncoming traffic. Through a group discussion, students begin to identify ways to discern which meaning to apply. A student might comment, If you were behind a truck for a long time and then all of sudden he turns on the left blinker, it could mean that you should pass. To be sure you might first check for oncoming traffic and if it is clear then it means to pass. Another student might say, If you are traveling in a hilly area on a winding road with no obvious cross roads ahead then it probably means to pass. Eventually the students understand the main idea that they have to look to the context to consider what meaning to apply. In other words, the meaning is tied to the cues in the specific context. I then translate this concrete example into more conceptual terms. In discerning the appropriate meaning, one must first entertain both sets of meanings or apply both sets of cultural lenses. Then one collects data to test both ideas. Ultimately, one weights the available evidence and then applies the meaning that appears to be most appropriate. It is important to note that whatever decision is made, there usually exists some degree of uncertainty. By collecting evidence to test the two possi-

8 TEACHING CULTURALLY INFORMED ASSESSMENT 233 ble meanings, the psychologist attempts to reduce uncertainty. With multiple assessments over time, greater certainty can be achieved. CONCLUSIONS Culturally informed assessment is a process a way of thinking critically about the role of culture in human behavior. Teaching a responsible cultural perspective can take many forms. My strategy is to establish a firm conceptual base and to engage students in key ideas through exercises and illustrations. I have found that these pedagogical tools help students develop a perspective that is both respectful and critical of culture s role in human behavior. Psychologists who can present evidence for and against cultural interpretations will be in the strongest position to convince others when culture matters most. ACKNOWLEDGMENTS The preparation of this manuscript was supported in part by Grant K08 MH01499 from the National Institute of Mental Health. Portions of this article were adapted from López (2000). REFERENCES Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, Betancourt, H., & López, S. R. (1993). The study of culture, race, and ethnicity in American psychology. American Psychologist, 48, Brofenbrenner, U. (1989). Ecological systems theory. In R. Vasta (Ed.), Annals of child development: A research annual. Vol. 6: Six theories of child development: Revised formulations and current issues (pp ). Greenwich, CT: JAI. Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the multitraitmultimethod matrix. Psychological Bulletin, 56, Clark, L. A. (1987). Mutual relevance of mainstream and cross-cultural psychology. Journal of Consulting and Clinical Psychology, 55, Cromwell, R. E., & Ruiz, R. E. (1979). The myth of macho dominance in decision making within Mexican and Chicano families. Hispanic Journal of Behavioral Sciences, 1, Cronbach, L. J., & Meehl, P. E. (1955). Construct validity in psychological tests. Psychological Bulletin, 52, Egeland, J. A., Hostetter, A. M., & Eshleman, S. K., III. (1983). Amish study, III: The impact of cultural factors on diagnosis of bipolar illness. American Journal of Psychiatry, 140,

9 234 LÓPEZ Escobar, J. I., Burnam, A., Karno, M., Forsythe, A., & Golding, J. (1987). Somatization in the community. Archives of General Psychiatry, 44, Jenkins, J. H., & Karno, M. (1992). The meaning of expressed emotion: Theoretical issues raised by cross-cultural research. American Journal of Psychiatry, 149, Kleinman, A., & Kleinman, J. (1991). Suffering and its professional transformation: Toward an ethnography of interpersonal experience. Culture, Psychiatry and Medicine, 15, López, S. R. (1989). Patient variable biases in clinical judgment: A conceptual overview and methodological considerations. Psychological Bulletin, 106, López, S. R. (1994). Latinos and the expression of psychopathology: A call for the direct assessment of cultural influences. In C. A. Telles & M. Karno (Eds.), Latino mental health: Current research and policy perspectives (pp ). Los Angeles: University of California Los Angeles. López, S. R. (2000). Teaching culturally informed psychological assessment. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp ). Mahwah, NJ: Lawrence Erlbaum Associates, Inc. López, S. R., Grover, K. P., Holland, D., Johnson, M., Kain, C. D., Kanel, K., Mellins, C. A., & Rhyne, M. C. (1989). The development of culturally sensitive psychotherapists. Professional Psychology: Research and Practice, 20, López, S. R., & Guarnaccia, P. J. (2000). Cultural psychopathology: Uncovering the social world of mental illness. Annual Review of Psychology, 51, López, S. R., & Hernandez, P. (1986). How culture is considered in the evaluation of mental health patients. Journal of Nervous and Mental Disease, 174, MacCorquodale, K., & Meehl, P. E. (1948). On a distinction between hypothetical constructs and intervening variables. Psychological Review, 55, Meehl, P. E. (1954). Clinical vs. statistical prediction. Minneapolis: University of Minnesota Press. Messick, S. (1980). Test validity and the ethics of assessment. American Psychologist, 35, Murphy, J. M. (1976). Psychiatric labeling in cross-cultural perspective. Science, 191, Shweder, R. A., & Bourne, E. J. (1984). Does the concept of the person vary cross-culturally? In R. A. Shweder & R. A. LeVine (Eds.), Culture theory: Essays on mind, self, and emotion (pp ). Cambridge, England: Cambridge University Press. Weisz, J. R. (1989). Culture and the development of child psychopathology: Lessons from Thailand. In D. Cicchetti (Ed.), The emergence of a discipline: Rochester symposium on developmental psychopathology (Vol. 1, pp ). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Zuckerman, M. (1990). Some dubious premises in research and theory on racial differences: Scientific, social and ethnical issues. American Psychologist, 45, Steven Regeser López Department of Psychology University of California Los Angeles, CA Lopez@psych.ucla.edu Received March 29, 2002