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Psychological assessment should be accurate, thorough, and impartial. This assertion, of course, rests on an incontrovertible presupposition: that clinicians are competent, especially in using reliable assessment procedures. Identifiable characteristics and inferential dimensions of a client's psychological status (e.g., symptom patterns, overt behaviors, and covert personality dynamics) as well as environmental influences should largely determine how the client is assessed. Therefore, if skilled clinicians could actually assess the same client, they should formulate similar conceptions of the client's psychological functioning. Moreover, if skilled clinicians could each independently assess several of the same clients, they should arrive at differential assessment conclusions appropriate to each client. In any case, clinicians should make accurate, comprehensive assessment decisions regardless of (a) their cultural backgrounds, (b) the client's cultural background, and (c) the complexity and nature of the presenting problem(s).
Despite the need for accuracy, thoroughness, and impartiality, psychological assessment can be an enigmatic process influenced by a myriad of social and psychological variables. Many of these variables are ubiquitous, but unfortunately, they are either overlooked or mishandled when making assessment decisions and formulating case conceptualizations. Culture is one such variable that permeates human experience. It affects the way people label illness, identify symptoms, seek help, decide whether someone is normal or abnormal, set expectations for therapists and clients, give themselves personal meaning, and understand morality and altered states of consciousness (Angel & Thoits, 1987; Comas-Diaz, Griffith, Pinderhughes, & Wyche, 1995; Eckensberger, 1994; Higginbotham, 1979; Kleinman, 1979; Landrine, 1992; Littlewood, 1990; Triandis, 1989; Ward, 1994). Sometimes clinicians give culture too much credence in assessment, resulting in their overlooking or underdiagnosing of psychopathology, or they may not give culture due consideration, resulting in their overdiagnosing of psychopathology (Lopez & Hernandez, 1986; Lopez & Nunez, 1987; D. Sue & Sue, 1987; S. Sue, 1988; Westermeyer, 1987). Ramirez, Wassef, Paniagua, and Linskey (1996) have put this problem into sharp focus:
A major challenge facing mental health providers who work with culturally
diverse clients is the determination of whether those clients' behaviors
reflect personality abnormalities or are normal within their cultural
context. Without the consideration of cultural group norms in the assessment
process, the probabilities of misdiagnoses and inappropriate treatment plans
increase significantly. (p. 284) Malgady (1996) shed further light on the problem, critiquing the very foundation of multicultural assessment practice and extending the problem beyond clinical practitioners: "Limited empirical data and even sparser theoretical preconceptions hinder researchers, professional practitioners, and policy makers in deciding whether or not--and, if so, how--a culturally informed mental health assessment ought to take place" (p. 73).
The purpose of this article is to reexamine, reconceptualize, and demonstrate how to intentionally incorporate culture into psychological assessment. We argue that despite the claim that multiculturalism is the fourth force in mental health treatment (Pedersen, 1991), current suggestions for assessing clients cross-culturally are woefully inadequate. Other multicultural specialists corroborate our criticism (e.g., Dana, 1993; Good & Good, 1986; Grieger & Ponterotto, 1995; Highlen, 1996; Rollock & Terrell, 1996; Sodowsky & Impara, 1996). For example, Grieger and Ponterotto (1995) stated "that the majority of counselors are not adequately trained to conduct accurate clinical assessments of clients who represent culturally diverse (particularly non-White, non-middle class) groups" (p. 357). Pedersen (1994b) sounded a more poignant alarm. He argued that no other practical issue in multicultural counseling is more urgent than is accurate assessment. Rollock and Terrell (1996) made perhaps the most disturbing comment, arguing that mainstream assessment procedures are dangerous for members of disadvantaged ethnocultural groups. They cited several findings to support their contention, including a tendency to equate sociocultural differences with deficiencies or abnormalities, the exclusion of members of these groups from educational and employment opportunities, and inappropriate labeling/ classification.
In this article, we examine the major unresolved issues and problems associated with multicultural assessment. We also propose a procedure for incorporating cultural considerations into assessment. To achieve our objectives, we organize the article into five major sections. First, in the next section, we discuss the importance of considering culture in assessment. In the second section, we set forth our philosophy of assessment. Third, we explore selected critical issues of relevance to multicultural assessment. We explain a procedure for incorporating culture in clinical decision making in the fourth section. In the fifth and final section, we provide a clinical case that demonstrates the use of our procedure. We begin by exploring the critical role culture plays in assessment and the importance of understanding that role.
THE IMPORTANCE OF CONSIDERING CULTURE IN ASSESSMENT
Psychological assessment always occurs within a cultural context (Good & Good, 1986). According to Draguns (1989), culture is an invisible and silent participant in counselor-client interactions. Added to the cultural context in which service delivery takes place is the fact that both counselors and clients are products of their respective cultures (Rollock & Terrell, 1996). This three-way interaction of the clinician's culture, client's culture, and cultural setting often gives way to misunderstanding. On this theme, Draguns (1989) stated,
The role of culture is even more obvious when clients and counselors of
different cultural backgrounds encounter one another. Expectations, meanings,
and unspoken assumptions have to be considered lest misunderstanding lead to
disappointment, frustration, and failure. If the role of culture is
overlooked, the flow of communication can become obstructed, and the
development of a relationship may be aborted. (p. 6)
Clinicians have several options in how to deal with culture. One option is to deny or to minimize it. To deny or to minimize culture, however, is to overlook reality. Clinicians who overlook reality make it almost certain that their perceptions of clients will be inaccurate. Numerous clinical cases can be found in the literature in which clinicians discounted cultural influences on client behavior (e.g., Lum, 1992; Martinez, 1988; Pinderhughes, 1989; Ramos-McKay, Comas-Diaz, & Rivera, 1988; J. W. Thompson, Blueye, Smith, & Walker, 1983). J. W. Thompson and colleagues' discussion of a patient labeled "crazy Indian" is a clinical case in point. Both the emergency room physician and a nurse, who saw the patient as impulsive and potentially violent, failed to account for cultural and circumstantial dimensions of the presenting problem. An Indian psychiatric resident, who was later called on, made the following observation:
In making my psychiatric assessment of this man's situation it was clear
that I was not being asked to deal with "pure" psychopathology... I knew
that if this man had been seen by a doctor with no training in cultural
psychiatry he might well have been diagnosed as psychotic and/or alcoholic,
deemed dangerous to himself and others, and committed to a psychiatric ward.
(J. W. Thompson et al., 1983, p. 271)
Contrary to the judgments of the other staff members, the psychiatric resident described the patient's problems in terms of unfulfilled basic needs as opposed to a mental disorder. The resident concluded that crisis intervention, using public and social services, was the treatment of choice. As the resident explained,
Seeing the inadequacies of our own hospital health care model, I knew
that the patient could receive help only if he were referred to the local
Indian health board or if I were to take the patient on myself in
individual crisis intervention. (J. W. Thompson et al., 1983, pp. 271-272)
The resident's judgment was based on the patient's description of a variety of social stressors, such as the mistreatment he experienced at the hands of White police and the legal system, his unemployment, his lack of housing, and the violation of his culture.
This clinical case dramatizes the insidiousness of judgmental errors in multicultural assessment--a potential problem that should always be investigated (Adebimpe, 1982). In recognition of this problem, Edwards (1982) conceptualized two types of diagnostic errors, as illustrated in Figure 1. A Type I error involves the designation of pathology where none exists, as in the attribution of violent and impulsive traits to being a "crazy Indian". Here, the practitioner concludes abnormalcy when, in terms of the client's situation and cultural norms, a less severe conclusion is warranted. Malgady (1996) pointed out that the null hypothesis many clinicians hold is that of no differences between ethnic groups. He cogently argued that it is time to reject this null hypothesis in favor of a more critical approach, which assumes differences until proven otherwise.
[Figure 1 ILLUSTRATION OMITTED]
On the other hand, clinicians also may overemphasize the role of culture, resulting in a Type II error. A Type II error involves the failure to identify actual pathology. There are cases when the practitioner concludes normalcy when, in terms of the client's situation and cultural norms, a conclusion of pathology is appropriate (e.g., D.O. Lewis, Balla, & Shanok, 1979; Ridley, 1995; Thomas & Sillen, 1972; Westermeyer, 1987). D.O. Lewis and colleagues (1979), for example, found that psychopathology was overlooked among African American juvenile offenders or that they were judged not to need mental health services. The researchers observed that clinicians misinterpreted the behavior of these adolescents as normative for low-income, urban African Americans. Specifically, clinicians judged recurrent hallucinations as culturally appropriate, dysfunctional paranoia as adaptive, extreme grandiosity as street bravado, and bizarre behaviors as manipulations. D. O. Lewis and colleagues suggested that these symptoms would not have been misinterpreted in White children. The researchers cited a case example:
A black child was transferred from a psychiatric hospital to a correctional
setting. The hospital staff dismissed his repeated ingestion of sharp objects
and his fluctuating states of awareness as manipulative acts in order to
remain in the hospital. The child also suffered from periodic auditory and
visual hallucinations which, while immediately evident to the nursing staff,
psychologist, neurologist, and psychiatrist at the correctional setting, had
been either overlooked or ignored during the child's nine previous
psychiatric admissions. (D. O. Lewis et al., 1979, p. 54)
Harkening the sentiment of Rollock and Terrell (1996), both Type I and Type II errors are dangerous to the well-being of clients. Because treatments are linked to assessments, erroneous clinical decisions logically lead to inappropriate interventions. In turn, inappropriate interventions contribute to unfavorable therapeutic outcomes.
The alternative to mishandling culture is to be culturally sensitive (Ridley, Mendoza, Kanitz, Angermeier, & Zenk, 1994; Zayas, Torres, Malcolm, & DesRosiers, 1996). Although acknowledging the inherent demands and difficulty of being sensitive to culture (Draguns, 1996; S. Sue, 1996; S. Sue & Zane, 1987), clinicians need not resign themselves to the supposed impossibility of this task. They can attempt to use culture to their client's advantage; to use culture is to maximize opportunities for therapeutic gain. Certainly, there may be occasions when counselors attempt to use culture and still fail. Nevertheless, because the counselors' goal is welfare of the consumer, we argue that attempts to consider culture are worthy of the counselors' time and effort. Trying is still better than is making no attempt at all, and such attempts more than likely will be appreciated by the client, which helps in building the therapeutic relationship. Ridley and colleagues (1994) crystallized the importance of cultural sensitivity:
Positive therapeutic outcomes depend on the skillful incorporation
of cultural considerations into the basic design of counseling
intervention. Conversely, behaving as if culture is irrelevant is
counter therapeutic. Such behavior results in an inadequate
understanding of individuals and an inability to
maximally assist them in achieving therapeutic goals. (p. 128)
Rogler (1992, 1993a, 1993b) specifically stressed the role of cultural sensitivity in assessment. Calling for the demystification of assessment, he postulated that the systematic and sensitive use of culture can improve the diagnostic process. Conversely, he argued that diagnostic errors cumulatively increase when clinicians neglect or misconceive culture. The problem is compounded by the complex interactions between culture and psychopathology (Al-Issa, 1982; Alarcon & Foulks, 1995; Alarcon, 1996). This makes assessment a challenging endeavor even when counselors are sensitive to culture.
To accede the importance of cultural sensitivity is to usher in a compelling challenge. Exactly how do clinicians incorporate culture in psychological assessment? We agree with Malgady (1996) that an empirically and theoretically informed approach to multicultural assessment does not exist. Not only were we unable to find such an approach in the literature, but we found indirect support for Malgady's claim. For example, Lopez and Hernandez (1987) discovered that clinicians were unable to describe how they assessed cultural factors, despite reporting that they gave these factors consideration. In other studies, Ramirez and colleagues (Ramirez, 1994; Ramirez et al., 1996) found that the large majority of mental health providers consider cultural issues to be important in the assessment of ethnic minorities. However, many of the providers did not consider themselves successful in assessing the degree of the client's assimilation and acculturation. Moreover, many of the providers indicated a need for more culturally focused training. In an attempt to elucidate the problem of considering culture in assessment, we articulate our stance on culture and then summarize and critique current suggestions for addressing this problem. In an attempt to find a solution to the problem, we reconceptualize the process. Both steps are necessary to provide a useful and informed procedure for multicultural assessment.
A Stance on Culture
Culture has been defined in a number of ways, depending on the theoretical, philosophical, and terminological stance of the theorists. Betancourt and Lopez (1993) reflected on the conceptual confusion of the construct in American psychology. They noted the special challenge that psychology faces in disentangling culture from related concepts such as race and ethnicity. In light of this challenge, we accept the following definition provided by Marsella and Kameoka (1989):
Culture is shared learned behavior that is transmitted from one generation to
another for purposes of human adjustment, adaptation, and growth. Culture has
both external and internal referents. External referents include artifacts,
roles, and institutions. Internal referents include attitudes, values,
beliefs, expectations, epistemologies, and consciousness. (p. 233)
We feel that this definition of culture is a solid attempt to meet psychology's challenge and has a number of important features relevant to assessment. First, the definition acknowledges that culture touches on practically every aspect of human experience. Therefore, to conduct complete, accurate assessments, clinicians must process a broad range of data. Second, culture is proposed to have external and internal dimensions. Consequently, some aspects of the client's psychological presentation may be obvious (i.e., external) and others, less so (i.e., internal). For example, an Arab client presents with symptoms of depression that began around the time he was laid off from work. His external cultural referent is the expectation to fulfill his role as provider for his family. His internal referent involves feelings of shame for not fulfilling his cultural role as an Arab male. Despite his best efforts to find another job, his layoff resulting from his company's downsizing instead of his work performance, and his depression following a significant personal loss, he still feels as though he has failed to live up to the expectations his culture places on him as a male and head of a household. This example clearly illustrates why a clinician needs to be cognizant of the client's internal and external referents. Both are at work in shaping the client's self-concept and contributing to his symptoms of depression.
Although it is not explicitly stated in the definition, we surmise a third feature of culture. Individuals vary considerably in their adherence to the internal and/or external referents of their cultures. Therefore, clinicians should anticipate within-group differences when conducting assessments. For instance, an Indochinese client with more traditional values may show clear deference to the clinician, indicating respect to an authority figure. However, the client's fear of shaming the family through disclosure of personal problems is elusive. Clinicians would be misdirected in assuming that the client's external behavior, a reluctance to self-disclose, merely reflects internal resistance. On the other hand, another Indochinese client may feel less bound to traditional cultural values. In fact, this client may have become bicultural, endorsing a combination of Southeast Asian and Western values. During therapy, the client may discuss her problems freely and feel less concern about protecting the family's image or seeing her difficulties only as a failure of the family.
The above example lends itself to a fourth feature of culture. The definition we endorse does not imply that the indigenous culture encompasses everything a person knows, thinks, and feels about the world (Keesing, 1974). Individuals may adopt attitudes, values, beliefs, and behaviors that are outside of the mainstream of their cultures. Therefore, clinicians should expect to encounter clients who have characteristics that are idiosyncratic and atypical of persons from heir culture. Fifth, the definition applies to any group that has shared learned behavior for the purpose of adjustment, adaptation, and growth. This may include groups defined by race, ethnicity, age, socioeconomic status, gender orientation, religion, or a history of social oppression. It behooves clinicians to look beyond more limited, traditional conceptions of culture and ascertain the particular internal and external referents of clients' cultures when conducting assessments.
Acknowledgment of the saliency of culture has led to the formulation of suggestions for practitioners to follow in the multicultural assessment process. We have gleaned 16 suggestions from the literature, which are described in this section. Although some of the suggestions slightly overlap in content, we attempted to distill them into identifiable categories. This discussion should enlighten readers as to the tremendous amount of reflection that has been put into multicultural assessment, provoke them to evaluate the adequacy of the suggestions, and prepare them for a reconceptualization of multicultural assessment--an undertaking we deem necessary based on the limitations of current suggestions.
1. USE EMIC CRITERIA
The emic approach to assessment categorizes and classifies psychological phenomena in terms of divergent attitudes, values, and behaviors arising out of specific cultures. This contrasts with the etic perspective that emphasizes universals among human beings (Dana, 1993; Draguns, 1996; Fabrega, 1989). Numerous scholars have indicated that there may be differences in symptoms associated with psychological disorders across various cultures (Canino & Spurlock, 1994; Foulks, 1991; Good, 1993; Katz et al., 1988; Ndetei, 1986; Phillips, 1996; Solomon, 1992). Therefore, clinicians are urged to conceptualize mental health functioning from the perspective of the client's indigenous culture instead of from that of external cultural standards (Kleinman, 1988; Malgady, Rogler, & Cortts, 1996). Using emic criteria serves as the basis for assigning either the same disorder to different symptoms or different disorders to similar symptoms across cultures. For example, Euro-Western cultural standards emphasize activity, autonomy, voluntarism, and self-reliance/independence (Alarcon & Foulks, 1995). Deviations from these values have been reflected in the definitions of personality disorders. On the other hand, these same deviations may be considered normal in other cultures. For instance, dependence is acceptable and considered necessary in Asian contexts (Blankfield, 1987).
Several major problems confront clinicians in the use of the emic approach. Many cultures do not have explicitly developed emic criteria, making them elusive to most clinicians. In addition, clinicians would have to painstakingly immerse themselves in a particular culture to appreciate its emic (Trimble, Lonner, & Boucher, 1983). Perhaps the most serious problem is the questionable validity of extreme cultural relativism (Good, 1993). Although clinicians may possess valid emic information, the inferences made from emic information will not be valid unless viewed within the context of etic principles.
2. USE STANDARDIZED INSTRUMENTS IN CULTURALLY APPROPRIATE WAYS
A relatively small number of tests are widely used in clinical practice and training (Craig & Horowitz, 1990; O'Donohue, Plaud, Mowatt, & Fearson, 1989; Piotrowski & Keller, 1989). The Minnesota Multiphasic Personality Inventory (MMPI) (and its substantial revision, the MMPI-2) as well as the California Psychological Inventory (CPI) are two extensively used measures of personality (Lonner & Ibrahim, 1996). Despite the wide usage of standardized tests, numerous problems concerning their use with diverse populations have been cited (Hinkle, 1994; Padilla & Medina, 1996; Reynolds & Kaiser, 1990; Suzuki & Kugler, 1995). Commonly cited problems are bias in test content, inappropriate standardization samples, examiner and language bias, inequitable social consequences, measurement of different constructs, differences in test-taking skills, lack of appropriate norms for various cultures, misinterpretation of test data, and problems in test administration. Because of these problems, Padilla and Medina (1996) argued that instruments normed on majority group populations cannot be blindly applied to people of color.
We acknowledge the sincere attempts to overcome these difficulties. The development of instruments such as the Millon Clinical Multiaxial Inventory-1 is one such effort. The inventory included representative percentages of minority groups in the standardization sample. However, racial differences in item endorsement and scale scores have been found (Gray-Little, 1995). The inclusion of non-Whites in the restandardization sample of the MMPI-2 is another such attempt. No substantial mean differences exist between representative groups (Butcher & Williams, 1992). However, although African and Native Americans are proportionately represented, Hispanic and Asian Americans are underpresented in the restandardization sample (Hathaway & McKinley, 1991). In addition to these problems, Dana (1995) reported that the majority of doctoral programs do not train students to use tests in culturally appropriate ways or provide them with many opportunities to examine culturally related interpretations of test protocols.
To counter these problems, clinicians are encouraged to engage in culturally sensitive testing (Dana, 1995; Padilla & Medina, 1996). Typically, they are asked to interpret test results with caution and to integrate relevant cultural data into the interpretation. Beyond these general suggestions, a potpourri of recommendations are found in the literature. Suzuki and Kugler (1995), for example, outlined a six-step testing procedure that includes (a) preassessment considerations, (b) knowing the referral question, (c) selecting the next step, (d) selecting appropriate instruments, (e) administering the tests, (f) behavioral observations, and (g) putting it all together. The authors gave specific actions to take for each step. When engaged in preassessment considerations, for example, they advised professionals to stay up-to-date regarding empirical findings in the use of tests with various populations. The advice is typical. Although helpful to some extent, the procedure gives no direct guidance about the most important tasks professionals face in using these instruments: interpreting test results with caution and integrating cultural data into their interpretations. The closest Suzuki and Kugler came to dealing with these issues is to recommend that clinicians consult with cultural experts and colleagues when they are in doubt about interpretation. We ask: "On what basis do cultural experts and colleagues interpret test data?"
3. USE NONSTANDARDIZED METHODS
Nonstandardized methods have been recommended as alternatives to standardized assessment (Lonner & Ibrahim, 1989, 1996). They differ from standardized techniques in that they are not developed or normed on well-defined populations (Shertzer & Linden, 1979). In addition, these methods are not based on fixed-response formats, preselected vocabularies, and other measurement deterrents to clients fully expressing themselves (R. A. Jones, 1977). Goldstein (1981) went so far as to suggest that tests with fixed response formats and preselected vocabularies should not be used in crosscultural assessment. Nonstandardized approaches in multicultural assessment have been grouped into several categories. Some of the techniques, however, appear in more than one category.
Postassessment narratives. This is a method of follow-up questioning and probing of the client to better understand responses obtained through psychological tests or formal psychiatric interviews (Gray-Little, 1995; E. E. Jones & Thorne, 1987). For example, the method has been suggested as an adjunct to the use of the Mental Status Exam and Diagnostic Interview Schedule. The purpose of postassessment narratives is to help counselors gain additional insights into how culture may influence client responses during the formal interview and possibly formulate new diagnostic impressions (Canino & Spurlock, 1994; Hendricks et al., 1983; E. E. Jones & Thorne, 1987; Newhill, 1990; Westermeyer, 1987). The process is based on the assumption that formal diagnostic interviewing may not yield valid data for certain populations. For instance, Hendricks and colleagues (1983) compared clinicians' impressions of African American adults using only the Diagnostic Interview Schedule, with their judgments based on open-ended probing. They found a low rate of agreement between the two methods. They also found more diagnoses of schizophrenia when clinicians only used the interview schedule.
Constructivist strategies. Lonner and Ibrahim (1996) suggested that constructivist strategies may be fruitful in multicultural assessment. These strategies are designed to give counselors an understanding of how clients construct reality. Lonner and Ibrahim identified several of these strategies including content analysis of a client's spoken or written narrative, discourse analysis of interactions within a group, journal work, and the repertory grid technique. The authors also indicated that projective techniques might be considered constructivist approaches.
Idiographic assessment. A number of authors have emphasized the need to understand clients' personal meanings as particular people and not simply as members of groups (E. E. Jones & Thorne, 1987; Malgady, Rogler, & Constantino, 1987; Ridley, 1995; Ridley et al., 1994; Tyler, Sussewell, & Williams-McCoy, 1985). Some of these authors have warned of the dangers of stereotyping, suggesting the alternative of examining the unique roles or aspects of clients' lives and how these roles collectively give clients meaning. Currently, the recommendation of idiographic assessment in the multicultural literature seems to be more of a philosophy than a systematic procedure. Hays's (1996) ADRESSING framework is a good example. The acronym stands for age and generational influences, disability, religion, ethnicity, social status, sexual orientation, indigenous heritage, national origin, and gender. According to Hays, the framework can be used to organize and examine the various cultural influences and identities affecting older clients. However, she did not provide clinical guidelines describing what content should be explored for each role and how to integrate the respective roles into comprehensive profiles of clients.
Miscellaneous methods. A variety of nonstandardized methods that are not easily categorized have been suggested for use in multicultural assessment (Dana, 1993; Lonner & Ibrahim, 1989). Some of the suggested methods are ethnographies, life history/case studies, accounts methods, methods for studying life events, and picture-story techniques. Effective use of some of these methods often depends on the assessor having extensive cultural knowledge of the target population. Presumably, this enables the assessor to better interpret the client's responses. E. E. Jones and Thorne (1987), for instance, described the narrative accounts method. This is a collaborative method of biographical interviewing. The purpose is to reconstruct a client's life story using open-ended and reflective dialogue. This approach to assessment is construed as an egalitarian and unfolding relationship.
Critique. Nonstandardized methods, especially projective techniques, have been considered by some experts to be more culturally sensitive than are objective measures (Gray-Little, 1995; Sundberg & Gonzales, 1981). Nonstandardized methods employ ambiguous stimuli, which are not assumed to be culture bound. In addition, unlike standardized techniques, these methods allow examinees to make maximal use of language in responding to the stimuli. Nevertheless, Gray-Little (1995) cited several concerns that threaten the validity of these techniques: (a) uncertainty about the amount of information needed to make an interpretation, (b) difficulty in verifying that the determinants of responses are basic and universal, and (c) absence of support for the equal adequacy of the techniques for all groups. Gray-Little also cited research demonstrating the vulnerability of projective interpretation to racial stereotypes and prejudgments. In addition, we believe that the extensive cultural knowledge purportedly required in the use of some nonstandardized methods is unattainable by many clinicians.
4. USE CULTURE-SPECIFIC INSTRUMENTS
Another suggestion in response to the inadequacy of standardized tests is the use of measures constructed for specific populations. E. E. Jones and Thorne (1987) pointed out the rationale behind the use of these instruments: "They more accurately reflect minority experiences, values, and personality characteristics than do conventional measures" (p. 490). The Handbook of Tests and Measurements for Black Populations (Vols. 1-2) (R. L. Jones, 1996), for example, provides a compilation of personality questionnaires, self-esteem scales, and identity measures for this population. E. E. Jones and Thorne (1987) argued that culture-specific measures unfortunately repeat the problems of conventional measures. Culture-specific measures attempt to assess shared cultural experiences for members of a population, but they do not adequately account for within-group variability.
5. USE THE DSM-IV WITH CULTURAL SENSITIVITY
One of the stated goals of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, American Psychiatric Association [APA], 1994) is to assist clinicians in evaluating diverse populations. The manual indicates that consideration should be given to the ethnic and cultural diversity of clients in the United States and internationally. Three major features have been incorporated in the manual to achieve this goal. First, cultural variations in the clinical presentations of the various disorders are discussed. This culture-specific approach attributes the content and form of symptomology to the client's cultural background. For example, the manual suggests that a preponderance of somatic symptoms rather than sadness characterizes depressive disorders in some cultures. Second, the manual has a glossary of culture-bound syndromes. These syndromes are recurrent, culturally specific patterns of aberrant behavior and troubling experience. The glossary identifies 25 of these conditions as well as the cultures in which the conditions were first described and briefly describes the nature of the psychopathology. According to the manual, a syndrome may be linked to a particular DSM-IV (APA, 1994) diagnostic category. Atague de nervios, for example, is a condition of distress found among Latinos. The condition is characterized by uncontrollable shouting, crying attacks, trembling, heat rising from the chest to the head, and verbal or physical aggression. Ataques may occur as normal stress reactions or in association with mental disorders. Third, the manual provides an outline for cultural formulation. The outline is designed to supplement the multiaxial diagnostic system and "assist clinicians in evaluating and reporting the impact of the individual cultural context" (APA, 1994, p. xxiv). The outline consists of five categories: (a) cultural identity of the individual, (b) cultural explanations of the individual's illness, (c) cultural factors related to psychosocial environment and levels of functioning, (d) cultural elements of the relationship between the individual and the clinician, and (e) overall cultural assessment for diagnosis and care. The manual suggests that clinicians provide narrative summaries for each of these categories. Castillo (1997) discusses in detail how to construct these narratives.
In addition to these major features, D. W. Smart and Smart (1997) pointed out two other changes that made the manual culturally sensitive. The definition of Axis IV was broadened to include psychosocial and environmental problems. Among the problems listed are difficulty with acculturation and discrimination. Also, the manual has a new condition--V62.4, Acculturation Problem. The category focuses on the client's adjustment to a different culture, and it is listed under the section called "Other Conditions That May Be the …