12.6 Cross-cultural assessments of mental disorder.

The most extensive research on mental disorder has occurred in the U.S. and Europe and practitioners elsewhere transferred Western assessments of mental disorder for use in their cultures. Mental disorder assessments have been developed over time in Western countries through the use of surveys or interview protocols, or by using relevant structured tasks requiring behavioral responses from the patient. The problems associated with the transfer of psychological test from one culture to another have discussed in this book. In the case of mental disorder assessments cultural variables may affect the specific expressions of distress by the patient and the words used in the original culture may translate poorly into another language. All the usual issues encountered in developing reliable and valid instruments are equally important in the cross-cultural assessments of mental disorder. In particular the comparability of constructs that are clinically measured must be verified. In interviews the differential impact of cultural values on interviewers and client must be understood for valid diagnosis (Draguns, 1997). Since varying definitions exist for disorders like schizophrenia instruments developed in one culture may not assess the unique meanings or expressions in another society.

Sensitivity to cultural values does not mean that clinical instruments cannot be transferred for use in a variety of cultures. However, the transferred assessment should be validated in each new society where it is to be used. The Child Behavior Checklist (Achenbach, 2001) has been used in a number of countries to asses behavioral and mood related problems. Differences in levels of behavior control have been found to exist between children from collectivistic societies compared to children from individualistic cultures (Crijnen, Yirmiya, & Verhulst, 1999). The cross-cultural use of assessment tools should be based on an understanding of the cultural norms for healthy development as well as the culturally specific criteria of abnormality and disorder. Researchers have suggested the importance of utilizing ideas from indigenous healing practices that might be efficaciously used in particular cultures (Lonner, & Ibrahim, 1989).

At the same time the cultural values of the therapist are salient to the perception of healthy and abnormal behavior. For the therapist appropriate behavior in one culture might reflect disturbed behavior in another society as the norms vary. For example the refusal of a woman to leave her home may be considered entirely normal in a fundamentalist Muslim society, but be seen as a sign of neurotic behavior in Western countries (Li-Repac, 1980). The cultural values of the therapist can produce diagnostic errors, particularly in multi-cultural societies, in the diagnostic process and also in interpretations of assessments. The culture of therapist and client vary frequently in multinational societies and an error in diagnostic judgment is possible unless the therapist is very sensitive to the cultural background of the patient. The best diagnostic and therapeutic results will probably be obtained when both therapist and patient have a common language and cultural value backgrounds.

Success can be reported for the transfer of assessments of psychopathology in a variety of cultures. The MMPI (Minnesota Multiphasic Personality Inventory) has been used successfully in number of cultures using standard scientific procedures of translation and back-translation to asses construct equivalence, and the use of bilingual test and retest procedures. The interpretations obtained cross-culturally were reported as equivalent to those obtained in the U.S. (Butcher, Lim, & Nezami, 1998). It has been argued that the equivalent results reported verify the universal structure of personality discussed previously, however personality deviations can also be observed reflecting cultural variables. It seems again that the best solution in psychological assessment is a combination of universal testing procedures combined with measures that are culturally sensitive.