& Chang, R. (2002). What questions arise when studying cultural
universals in depression? Lessons from abnormal psychology textbooks. In W. J. Lonner, D. L. Dinnel, S. A.
Hayes, & D. N. Sattler (Eds.), Online Readings in Psychology and
Culture (Unit 9, Chapter 2),
Center for Cross-Cultural Research, Western Washington University,
Bellingham, Washington USA.
This material is copyrighted by the author(s), who have kindly extended to the Center the right to use the material as described in the Introduction to this collection and the form entitled "Agreement to Extend License to Use Work."
UNIT 9, CHAPTER 2
WHAT QUESTIONS ARISE WHEN STUDYING CULTURAL UNIVERSALS IN DEPRESSION? LESSONS FROM ABNORMAL PSYCHOLOGY TEXTBOOKS
Junko Tanaka-Matsumi, Kwansei Gakuin
Robert Chang, Hofstra University, U.S.A.
We examined 70 abnormal psychology textbooks published from 1920s to the present to identify consistent cross-cultural themes with regard to human depressive experiences over time and across regions of the world. The cultural and cross-cultural literature on abnormality and depression, in particular, has contributed to widening the scope of abnormal psychology textbooks over time. However, the texts are almost entirely dependent on Western diagnostic categories, particularly with regard to definitions of depression. Within the Western classification framework, authors of abnormal psychology textbooks have increasingly recognized the role of culture in depressive experiences and their communication. On the basis of our content analysis of the textbooks, we propose 10 culturally informed questions to study the relationship between culture and depression.
At the 1999 annual convention of the American Psychological Association, Division 1 (General Psychology) hosted a symposium, "Are there cultural universals in psychopathology?" We (Tanaka-Matsumi & Chang, 1999) participated in this symposium. Reflecting Division 1's spirit of "coherence" and "unification" (Staats, 1999) within the diverse discipline of psychology, we asked, " What questions arise when studying cultural universals in depression?" At least in the Western world, people have used the terms melancholia and depression and their cognates to describe a diversity of dejected states for well over 2000 years (Jackson, 1986). To find unifying themes concerning socio-cultural constructions of depression over time, we looked into the rich texts of abnormal psychology. If there were reliable cultural universals, such themes should appear in the basic texts of abnormal psychology. We sought to identify questions regarding interactive patterns between panhuman biological conditions and socio-cultural constructions of depression in such texts. Figure 1 displays our conceptual scheme for classifying cross-cultural studies of depression in light of the three orientations of absolutism, universalism and relativism to cross-cultural psychology (Berry, Poortinga, Segall, & Dasen, 1992) with varying degrees of cultural and biological influences. The overlapping areas represent two principal elements of biological and cultural conditions relevant to depression, and psychopathology in general. The purpose of this manuscript is to report the result of analyzing depression-specific contents of 70 abnormal psychology textbooks published in English between 1927 and 2002.
Historically, since ancient Greek times, themes of personal loss, disruption of social roles, sudden changes in one's environment have been linked to feelings of dejection, anger, and even severe melancholia (Jackson, 1986). Cross-cultural researchers have adopted both emic (culture-specific) and etic (pan-cultural) positions and have developed interesting and different research questions regarding experiences of depressions across cultures (Tanaka-Matsumi & Draguns, 1997). The Western psychiatric literature did not report clinical cases of depression in sub-Saharan Africa in the first half of the 20th century. Prince (1968) questioned if the sudden increase in the prevalence of depression in Africa after mid-1950s reflected a "fact or diagnostic fashion." The anthropologist Field (1960) conducted a fieldwork in rural Ghana with Ashanti women and reported that depression was actually common in Africa. She extended the search into local villages and shrines instead of Western-oriented hospitals and clinics in Ghana. Authors of abnormal psychology textbooks began citing Field's anthropological study as evidence for universality of depression (e.g., Coleman, 1964). In the 1970s several authors published scholarly reviews of the literature on culture and depressions (e.g., Fabrega, 1974). Marsella (1980) concluded his review that "the major problem facing researcher on depression today is one of conceptualization" (p. 278). Researchers of culture and psychopathology have documented cultural similarities and differences in various aspects of depression (Kleinman & Good, 1985; Tanaka-Matsumi, 2001). However, to what extent are the important findings of cross-cultural psychopathology reflected in basic texts of abnormal psychology? Using a narrative format, we trace the development and dissemination of culturally-informed findings about depression as viewed through 75 years of published textbooks.
Specifically, we examined abnormal psychology textbooks published since 1927 to identify consistent cross-cultural themes with regard to human depressive experiences over time and across regions of the world. First, we examined the presence or absence of cultural factors in the definition of abnormality in each text. Second, we examined if the textbook definitions of depression included any cultural factors. Third, we examined what the texts said about depression and culture.
Selecting Abnormal Psychology Textbooks
We included the time span of 75 years from 1920s (Colvin, 1927) to the present (Comer, 2002). We selected 70 texts (see Table 1). One text (1.4%) was published in 1920s, 1 (1.4%) in 1930s, 3 (4.3%) in 1940s, 2 (2.9%) in 1950s, 6 (8.6%) in 1960s, 22 (31.4%) in 1970s, 12 (17.2%) in 1980s, and 15 (21.4%) in 1990s, 8 (11.4%) in/after 2000. We included multiple editions of 12 textbooks (e.g., Coleman; Davison & Neale). We identified published texts using five university libraries in New York, several Internet sites (e.g., Yahoo.com, Amazon.com), and popular college textbook stores in New York City. The oldest textbook we found was Colvin's (1927) Principles of Abnormal Psychology. Textbooks are updated constantly and replaced with new ones. This is probably why we could not find more of earlier editions or volumes even in the university libraries. All textbooks were published in English. With only two exceptions, all the textbooks were published in the United States.
Seventy Abnormal Psychology Textbooks Reviewed: 1927-2002
Year Author Edition
1. 1927 Colkin
2. 1937 Fisher
3. 1940 Brown
4. 1941 Maslow
5. 1947 Page
6. 1951 Maslow & Mittelmann Revised
7. 1956 Coleman 2nd
8. 1964 Coleman 3rd
9. 1965 Rosen & Gregory
10. 1965 Strange
11. 1968 London & Rosenhan
12. 1969 Ullmann & Krasner
13. 1969 Southwell & Feldman
14. 1970 Suinn
15. 1970 Cole
16. 1972 No author
17. 1972 Sarason
18. 1972 Vetter
19. 1972 Rosen, Fox, & Gregory 2nd
20. 1972 Coleman 4th
21. 1974 Davison & Neale
22. 1974 Kleinmuntz
23. 1975 Nathan & Harris
24. 1975 Page 2nd
25. 1975 Ullmann & Krasner 2nd
26. 1975 Suinn
27. 1976 Zax & Cowen
28. 1976 Coleman 5th
29. 1977 Reiss, Peterson, Eron, & Reiss
30. 1977 Martin
31. 1977 Goldenberg
32. 1977 Calhoun, Acocella, & Goldstein
33. 1978 Allman & Jaffe
34. 1978 Davison & Neale 2nd
35. 1979 Duke & Nowicki
36. 1980 Coleman, Butcher, & Carson 6th
37. 1981 Sue, Sue, & Sue
38. 1981 Martin 2nd
39. 1982 Davison & Neale 3rd
40. 1983 Schumer
41. 1983 McMahon & McMahon
42. 1984 Sarason & Sarason 4th
43. 1986 Sue, Sue, & Sue 2nd
44. 1986 Price & Lynn 2nd
45. 1986 Davison & Neale 4th
46. 1989 Costin & Draguns
47. 1993 Sarason & Sarason 7th
48. 1994 Van Hasselt & Hersen
49. 1995 Rosenhan & Seligman 3rd
50. 1995 Kendall & Hammen
51. 1996 Sarason & Sarason 8th
52. 1996 Wilson, Nathan, O'Leary & Clark
53. 1997 Sue, Sue, & Sue 5th
54. 1997 Nevid, Rathus & Green 3rd
55. 1997 Durand & Barlow
56. 1998 Nietzel, Speltz, McCauley & Bernstein
57. 1998 Oltmanns & Emery 2nd
58. 1998 Kendall & Hammen 2nd
59. 1998 Comer 3rd
60. 1998 Davison & Neale 7th
61 1999 Barlow & Durand 2nd
62 1999 Alloy, Jackson, & Acocella 8th
63 2000 Carson, Butcher, & Mineka
64 2000 Emery & Oltman
65 2000 Nevid, Rathus, & Greene
66. 2000 Durand & Barlow 2nd
67. 2001 Barlow & Durand 2nd Media Ed.
68. 2001 Davison & Neale 8th
69. 2001 Seligman, Walker, & Rosenhan 4th
70. 2002 Comer 3rd
We have provided name(s) of the author(s) and the year of publication of each of the 70 abnormal psychology textbooks that we surveyed for this study. Cited textbooks are not listed in the reference section.
Content Analysis of Abnormal Psychology Textbooks
We coded for three types of information. We examined whether the authors included culture in: (1) the definition of abnormal behavior in general; (2) the definition of depression and affective disorders in specific chapters; and (3) descriptions and reviews of the literature on depression. The current authors verified coding reliability by independently judging whether or not the relevant pages that we had extracted from the texts contained cultural information. The reliability was 100% for judging the presence or absence of the culture-relevant key words (see method).
Result of Content Analysis
Cultural Definitions of Abnormality
We first examined the definition of abnormality or psychopathology. We usually found the definition in the opening chapter of the text. We used chapter headings, subject index and table of contents and looked for key words: culture, cross-cultural, socio-cultural, minorities/race, abnormality, abnormal behavior, psychopathology, and mental illness. With the exception of one textbook, all other textbooks (97%) referred, in varying degrees, to socio-cultural factors in the definitions of abnormality.
Almost all the texts we reviewed acknowledged the role of culture in the shaping of abnormal behavior. Specifically, cultural bases of abnormal behavior referred to the importance of norms, expectations, social structures, and their relativities across cultures.
In one of earlier textbooks, Maslow and Mittelmann (1941) reviewed, "Normality is always relative to the particular culture or subculture in which the person lives... normality is also relative to status, age, and type of personality" (p. 37). Much later, Davison and Neale (1974) stated explicitly, "Labeling someone or some behavior as abnormal is inextricably linked to a particular social or cultural context" (p. 45). Similarly, Vetter (1972) wrote, "There are very few acts which would be considered deviant in all cultures or even considered deviant in the same culture in different historical periods" (p. 5). Ullmann and Kranser (1969) maintained, "Behavior is abnormal if and only if the society labels it as such" (p. 14). By 1999, Barlow and Durand concluded, "...cultural factors influence the form and content of psychopathology and may differ even among cultures side by side in the same country" (p. 57). The universality view commonly stated that psychopathology exists in all cultures. Earlier, Page (1947) stated, "Every race has its quota of psychological deviants" (p. 87). Yet, he also stated, "As yet no studies have been made with respect to the relative incidence of mental abnormalities among whites, Indians, and Orientals" (p. 88). Some texts also adopted a combined etic-emic approach, namely, psychopathology is a universal phenomenon but its social display varies widely across cultures.
Antecedents to the Rise of the Socio-Cultural Model in Abnormal Psychology
Comer (1998) attributed the rise of the socio-cultural model to three events: (1) the publication of Holllingshead and Redlich's (1958) community study on the relationship between social class and mental illness; (2) Thomas Szasz's (1960) proposition that mental illness is a "myth" created by Western society; and (3) the development of family theory and therapy. Additionally, in other textbooks, we found the following five elements as contributing factors for the development of cultural relativity view of psychopathology.
1. Anthropological field studies (e.g.,
Benedict, Mead) published in 1940s and 1950s emphasized behavioral variability
2. Ullmann and Krasner's (1969) text "A Psychological Approach to Abnormal Behavior" presented a comprehensive socio-cultural view of abnormal behavior.
3. Rosenhan's study (1973) "on being sane in insane places" increased criticisms of diagnostic judgments including their lack of reliability, and by extension, the potential for misdiagnosis for culturally different patients.
4. Multicultural movements in the United States gave an impetus to reviewing ethnic minority groups in abnormal psychology textbooks particularly from late 1980s to the present.
5. Kleinman's cultural perspectives began to appear in abnormal psychology texts published in 1990s.
Definitions of Depression and Culture
Although we found that 97% of the texts included references to cultural factors in the definitions of abnormality, we found that almost all textbooks adopted the Western categories of mental disorders. The tendency to use Western categories of mental disorders became prominent with the publication of the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM III: American Psychiatric Association, 1980). The texts were organized according to the DSM-based categories. Only three textbooks (4%) referred to culture in describing depression. First, Ullmann and Krasner (1969) defined depression as a "cultural role." Second, Kleinmuntz (1974) used the words "cultural depression" (p. 42) to describe the suffering of Black Americans. Third, Nevid and Rathus (1997) stated, "Depression might be close in meaning to the concept of "soul loss" in non-Western societies rather than sense of loss of purpose in life as in Western societies" (p. 7).
Emerging Themes in the Reviews of the Literature on Depression and Culture in Abnormal Psychology Textbooks
Of the 70 abnormal psychology textbooks, 34 texts (49%) presented cultural issues, while the remaining 36 texts (51%) presented nothing about culture and depression in the appropriate chapters. This finding suggests that the vast amount of literature now available on culture and depression is not integrated in the mainstream abnormal psychology texts. We found very few references to cultural factors from 1920s through 1960s. During this long period, only two texts (Coleman, 1964; Ullmann & Krasner, 1969) referred to cultural factors in depression and cited Field's report from Ghana (1960). Coleman (1964) quoted Field's statement that "the symptoms of involutional reactions are pretty much the same the world over" (p. 346). Ullmann and Krasner (1969) described depression as a social role and that it is frequent in "disintegrating individually anarchistic societies, no matter how primitive" (pp. 421-423). Overall, however, we did not find any systematic review of the cross-cultural literature.
Beginning in 1975, we found more consistent and systematic reviews of the studies on depression and culture. Page (1975), for example, wrote that guilt feelings and self-accusation are related to the Judeo-Christian tradition. In a summary of the texts during this period (1960s and 1970s), the authors considered depression and/or affective disorders are universal human experiences with variations in the relative frequency and, possibly, forms of the disorder (e.g., Martin, 1977). We identified the following themes relating to depression and culture in the texts.
Universality of depressive experiences. Of the 70 textbooks, 26 (37%) included statements of universality of depressive experiences. Examples are: "Depressive reaction seems to occur throughout the preindustrial world" (Allman & Jaffe, 1978); "Although affective disorders exist in almost all cultures, their relative frequency varies considerably" (Martin, 1981, p. 357); and "Depression is indeed a worldwide phenomenon: persons in all countries and cultures are at risk for it " (Comer, 1998, p. 260). However, only 3 textbooks (Oltmanns & Emery, 1998; Wilson, Nathan, O'Leary, & Clark, 1996; Costin & Draguns, 1989) cited international studies suggesting universality. Only one textbook (Oltmanns & Emery, 1998) cited the World Health Organization's (1983) cross-national study of depression, although it was the first international depression study that tested the utility of a standardized assessment in five countries.
Cultural influences on the reporting of depressive symptoms. We found that 26 texts (37%) elaborated on the relationship between depression and cultures. Two major issues emerged concerning the experience and communication of depressive symptoms. The first issue concerned psychological versus somatic symptom presentations. Selected texts began citing works by Marsella (1980), Draguns (1980), and Kleinman & Good (1985) and recognized that symptoms of depression vary across cultures. The most prominent theme was the Western versus non-Western differences in the mode of expressing "depression," particularly along the dimensions of psychological-cognitive symptoms (dysphoric mood, loneliness, sadness, indecision) in Western cultures and somatic-physical symptoms (fatigue, weakness, sleep disturbance, and weight loss) in non-Western cultures (Kleinman, 1982).
The second issue concerned guilt feelings and depression across cultures. Page (1975) connected guilt to the Judeo-Christian religion. Martin (1977) analyzed social structure and the individual responsibility and stated, "In African cultures depressive reactions almost never involve guilt, personal sinfulness, and self-reproach seen in many Western cultures" (p. 409). In 1980s and 1990s, we found a number of overlapping statements that "in many non-western or non-industrialized cultures, therefore, depressive symptoms may be reported as bodily symptoms" (Kendall & Hammen, 1995, p. 229).
Dichotomous categorization of cultures. We rarely found substantive definitions of culture, although references were made to differences in values, customs, and languages. Rather, we found dichotomous descriptions and labeling of cultures. We list some of the examples: (1) simple-complex, (2) Western- Non-Western, (3) technologically advanced-less advanced, (4) primitive-civilized, (5) Eastern-Western cultures, and (6) industrialized and preindustrialized cultures. By far, the most common dichotomy was Western versus non-Western cultures. However, what it means to be Western or non-Western culture was rarely described.
Gradually, reflecting the emerging cultural and cross-cultural literature in 1990s, authors of abnormal psychology textbooks began elaborating on cultural characteristics in terms of independent-interdependent self-orientations and individualism-collectivism.
Language and diagnostic implications. A few textbooks extended the review of cross-cultural differences in symptom reporting to diagnostic issues. Kendall and Hammen (1995) alerted, for example, to the possibility that, due to emphasis on somatic symptoms, "some cultural groups in the U.S. may not be appropriately diagnosed or treated" (p. 229). Furthermore, in one of more culturally informed textbooks, Oltmanns and Emery (1998) stated, "words and concepts that are used to describe illness behaviors in one culture might not exist in other cultures" (p. 167). Their conclusion was: "At its most basic level, clinical depression is a universal phenomenon that is not limited to Western or urban societies. They also indicate that a person's cultural experiences, including linguistic, educational, and social factors, may play an important role in shaping the manner, in which different people express and cope with the anguish of depression" (P. 167).
Unified psychology is the integrated study of psychology (Staats, 1999). As we have reviewed, much has been accomplished in developing sociocultural models of abnormality and disseminating important findings of cross-cultural research on depression. At the same time, much remains to be included in mainstream abnormal psychology texts. We have identified the following issues in our review of abnormal psychology texts published since 1927:
1. There has been a steady increase in
the review of the literature on culture and depression.
2. Authors recognized cultural relativity in the communication and reporting of depressive experiences.
3. Yet, many of the texts lacked cultural considerations in the definition of depression.
4. After 1980 most all texts followed standard mental disorder categories provided by the DSM systems (III - IV).
5. Language of depression varies considerably across cultures.
6. Culture has historically been categorized dichotomously (e.g., Western versus Non-Western) in abnormal psychology texts.
7. Few, if any, authors acknowledged cultural variations in the treatment of depression, although a few authors alerted readers to potential cultural bias in the diagnosis of depression due to cultural differences.
8. We noted a serious lack of attention to the measurement questions: Are there culturally reliable and valid measures of depression?
Based on our review of the textbooks, we recommend that authors of abnormal psychology textbooks explore conceptual and empirical answers to the following questions (Tanaka-Matsumi, 2001):
1. What is depression and how is it
2. What words are used to describe "depression"?
3. Are different words conceptually equivalent across cultures?
4. How do we test conceptual equivalence?
5. What aspects are known to be universal so far?
6. What aspects are known to be culturally variable?
7. How do we measure depression reliably and validly across cultures?
8. What would account for cultural differences including self-orientation, family structure and social network, individualism and collectivism, independent-interdependent self-orientations, mind-body dualism versus diffusion of the two?
9. How does one communicate depression to others in the same culture and how do we explain differential patterns of depressive communications across cultures?
10. What are the assessment and treatment implications of universality and cultural relativity in psychopathology?
About the Authors
Junko Tanaka-Matsumi is Professor in the Department of Psychology at Kwansei Gakuin University, Nishinomiya-City, Japan. She is also Professor Emeritus of Psychology at Hofstra University in Hempstead, New York, where she taught clinical psychology and cross-cultural psychology for over 20 years, until 2000. She received her Ph.D. in clinical psychology from the University of Hawaii. She is an Associate editor of the Journal of Cross-Cultural Psychology and conducts studies on culture and psychopathology, and functional analytic approaches to cross-cultural behavior therapy. E-Mail: Jmatsumi@Kwansei.ac.jp
Robert Chang is a Ph.D. candidate in the Combined Clinical and School Psychology Program at Hofstra University, Hempstead, New York. He earned his B.A. in psychology from the Pennsylvania State University and his M.A. in clinical-school psychology from Hofstra University. He is currently working on his doctoral dissertation on cultural factors related to somatization among Chinese American. His research interests include acculturation, acculturative stress, symptom attribution, somatization, and attitudes toward seeking psychological help among Asian Americans. E-Mail: firstname.lastname@example.org
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Questions for Discussion
1. Discuss various definitions of
abnormality and examine the role of culture in abnormal behavior.
2. What methodological difficulties do you anticipate when investigating the relationship between depression and culture?
3. Review various reports concerning universality and cultural relativity of depressive experiences.
4. What are some of the major landmarks for the development of culturally-informed literature on abnormal psychology?
5. What are the pros and cons of using the Western-derived diagnostic systems such as the DSM-IV (Diagnostic Statistical Manual of Mental Disorders-4th Edition) when studying psychological disorders in different cultures?
6. Are other forms or types of psychopathology or abnormal psychology better candidates for universality than depression? Explain your answer.
7. Locate a recent journal article that focuses on depression, making sure that it is based on only one culture or nation or ethnic group. Do you think the results of the study or article makes sense across cultures? Explain.