Literature Review

Prior to beginning work on this assignment, read the Ryder, Ban, & Chentsova-Dutton (2011) “Towards a Cultural-Clinical Psychology,” American Psychological Association (2014) “Guidelines for Prevention in Psychology,” Hage, et al. (2007) “Walking the Talk: Implementing the Prevention Guidelines and Transforming the Profession of Psychology,” and Rivera-Mosquera, et al. (2007) “Prevention Activities in Professional Psychology: A Reaction to the Prevention Guidelines” articles.

Clinical and counseling psychology is a dynamic field that is constantly evolving and striving toward better treatment options and modalities. In this literature review, you will explore and integrate psychological research into a literature review, addressing current trends in three major areas of clinical and counseling psychology: assessment, clinical work, and prevention.

In your review, include the following headings, and address the required content.

Assessment
Support this section with information from the Ryder et al. (2011) article “Towards a Cultural-Clinical Psychology” and at least one additional peer-reviewed article

  • Compare the assessments currently in use by clinical and counseling psychologists.
  • Explain the trend towards cultural-clinical psychology and the suitability of clinical assessments with diverse clients.

Clinical work
Support this section using a minimum of three peer-reviewed articles. The recommended articles for this week may be useful in generating your response.

  • Compare and contrast technical eclecticism, assimilative integration and theoretical integration.
  • Provide a historical context and identify the major theorists for each perspective.
  • Assess the trends in psychotherapy integration.
  • List three pros and cons for each perspective, sharing which perspective most closely aligns with your own.
  • Analyze the major trends in psychology and explain the connection between evidenced-based practices and psychotherapy integration.

Prevention
Review the “Guidelines for Prevention in Psychology” (American Psychological Association, 2014), and support this section with information from the Hage, et al. (2007) “Walking the Talk: Implementing the Prevention Guidelines and Transforming the Profession of Psychology,” and Rivera-Mosquera, et al. (2007) “Prevention Activities in Professional Psychology: A Reaction to the Prevention Guidelines” articles.

  • Describe general prevention strategies implemented by clinical and counseling psychologists at the micro, meso, exo, and macro levels.

The Literature Review

  • Must be 7 to 10 double-spaced pages in length (not including title and references pages) and formatted according to APA style
  • Must include a separate title page with the following:
    • Title of paper
    • Student’s name
    • Course name and number
    • Instructor’s name
    • Date submitted
  • Must use at least seven peer-reviewed sources in addition to the course text.
  • Must document all sources in APA style .
  • Must include a separate references page that is formatted according to APA style

    Prevention Activities in Professional Psychology: A Reaction to the Prevention Guidelines

    Evelyn Rivera-Mosquera Department of Mental Health, Columbus, Ohio

    E. Thomas Dowd Kent State University

    Marsha Mitchell-Blanks Cleveland State University

    In this reaction article, the authors provide a historical context for prevention activi- ties and their place in psychological practice. They then discuss the prevention guide- lines in the Major Contribution authored by S. M. Hage et al. (2007 [this issue]) and provide their critique. Finally, the authors offer ideas for the future specific applica- tions of these general guidelines and illustrate with a case example.

    Hage et al. (2007 [this issue]) are to be commended for their compre- hensive, thorough, and thoughtful contribution. They have managed to pull together the relevant literature regarding prevention efforts and its support- ing research, as well as organize this work into a set of aspirational guide- lines. The scope of their efforts is truly impressive—a scope that has its own problems as well as its obvious successes. This response will first pro- vide a brief historical context for prevention activities, and then provide a general response to these guidelines. We will conclude with ideas of our own for future applications of these guidelines and prevention in general.

    HISTORICAL OVERVIEW OF PREVENTION

    Hage et al. (2007) correctly state that prevention activities have histor- ically been an important aspect of the practice of counseling psychology (p. 497). This is consonant with counseling psychology’s developmental approach to mental health as compared with the more remedial approach of clinical psychology and the more case management approach of social work. Community psychology as a professiponal psychological specialty was

    Correspondence concerning this article should be addressed to Evelyn Rivera-Mosquera, Minority Behavioral Health Group, 1293 Copley Road, Akron, OH 44320; e-mail: rivera-mosquera @sbcglobal.net.

    THE COUNSELING PSYCHOLOGIST, Vol. 35, No. 4, July 2007 586-593 DOI: 10.1177/0011000006296160 © 2007 by the Division of Counseling Psychology

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    originally intended to focus more on prevention (and ironically consists pri- marily of clinical psychologists), but it has never had the impact its founders envisioned. Although prevention has been an important part of counseling psychology since its early years, the authors note the paradoxi- cal finding that despite a growing interest in prevention, counseling psy- chologists’ actual prevention activities are quite limited (Hage et al., 2007, p. 498). The reasons, we suspect, are largely economic. The field of mental health, like that of physical health to which status it has consistently aspired, is now and always has been remedial in orientation. There is little money to be made in prevention, and during the 1970s and 1980s counseling psy- chology attempted to play “catch-up” to clinical psychology in obtaining third-party reimbursements for its services to individuals. Third-party pay- ers in both medicine and psychotherapy typically do not pay for prevention, although in the long run it is cheaper than remediation. Therefore, advo- cating for preventive mental/physical health activities is likely to be a hard sell indeed, especially given the comprehensive, multiple causal factors, contexts, and domains to which Hage et al. argue we should devote our efforts (p. 529).

    REACTION TO THE GUIDELINES

    Overall, the guidelines appear to be well grounded in research, and the authors do a superb job of building their case for prevention. They demon- strate how the development of these guidelines evolved over time and were based in sound research as well as systemically discussed by key stake- holders before they were promulgated. This process gives the guidelines much more credence and potential for acceptance by the entire psycholog- ical community. The authors have taken a complex and convoluted area of practice/research and narrowed it down to guidelines that can help psy- chologists conceptually organize how they might best begin to engage in prevention work. While the guidelines are phrased in very cautious lan- guage that may make them more politically acceptable in some quarters, they may also fail to provide forceful guidance for significant change in the practice of psychology.

    The authors’ categorization of the guidelines into four conceptual areas (practice, research and evaluation, education and training, and social and political advocacy) is critical because it sets up the conceptual framework for the areas in which psychologists should be engaging in order to do prevention (Hage et al., 2007, p. 501). These domains will be discussed in more detail in the following sections.

    Practice

    The practice guidelines set the broad overarching guidelines for the practice of prevention. Guidelines 1–5 describe the basic elements neces- sary for the practice of prevention. Hage et al. (2007) use this section to call for psychologists to actively engage in the practice by (a) developing pro- active programs that prevent human suffering; (b) basing prevention pro- grams in empirical research; (c) using culturally relevant prevention practices as well as engaging key stakeholders in all levels of the planning and implementation process; (d) addressing both individual and social con- textual factors; and (e) focusing on both reducing risks and promoting the strengths of the targeted groups (pp. 501-519). These best practices build upon the general principle of justice and respect for people’s rights and dignity (Hage et al., 2007, p. 495). We agree that these should be the core compo- nents in the practice of prevention, and are especially pleased that cultur- ally relevant prevention was included as one of the top three guidelines. It is critical that programs targeting marginalized groups such as ethnic minorities, the hearing impaired, Appalachian, lesbian/gay/bisexual/trans- gender, and other cultural groups adapt their programs to meet the cultural and linguistic needs of the population as well as involve the stakeholders from these communities at all levels of the planning and implementation process (Reese & Vera, 2007).

    Research and Evaluation

    This domain (Guidelines 6–9) was the most difficult for us to “wrap our heads around” conceptually; in part, this may be because of the sheer com- plexity of prevention literature. Although the term prevention science was coined at a National Institute of Mental Health prevention conference in 1991, it does not appear to have infiltrated the field of psychology to its fullest extent. Thus, psychologists may not be as familiar with the field as other disciplines such as public health and social work (Hage et al., 2007, pp. 519-533). Undoubtedly, the field of psychology needs to actively engage in prevention efforts that are accurately targeted, efficiently executed, rigorously evaluated and that focus on the systemic empirical study of risk and protective factors impacting health and psychological dysfunction (Bloom, 1996).

    We liked the authors’ use of the National Institute of Mental Health’s cate- gorization of prevention research that classifies prevention research into three functions (preintervention epidemiology, preventive intervention [primary, secondary, and terciary], and prevention service delivery system) and three levels (biological, psychological, and sociocultural; Hage et al., 2007, p. 520). This classification matrix can guide prevention researchers toward literature

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    they need to examine prior to conducting their studies, as well as help them identify future directions for research based on their findings (Waldo & Schwartz, 2003).

    We agree wholeheartedly with Guideline 7 that calls for psychologists to be competent in a variety of cross-disciplinary research methods, both quali- tative and quantitative. We want to point out that the potential number of con- textual variables and the possible interaction effects that Guideline 8 alludes to, which may occur in prevention research, are truly mind-boggling. Guideline 9 (ethical issues) is very important and perhaps deserves a domain of its own because prevention research can be fraught with ethical dilemmas.

    Education and Training

    This domain (Guidelines 11 and 12), in our estimation, is one of the most important sections because psychologists must be educated early in their training on the how and why to engage in prevention and social jus- tice issues, if they are to do so later in their careers. The guidelines appear to be geared toward psychologists who have completed their PhD training rather than current PhD students. We would like to see prevention theory, research, and practice worked into the curriculum of every psychology stu- dent at all levels (BA, MA, PhD, and PsyD) in order to prepare future psy- chologists in the prevention field, much like social work has done in the National Association of Social Workers’ policy statement on mental health (National Association of Social Workers, 2003–2006). This prevention training should seek to expand psychologists’ repertoire of skills to include cross-disciplinary training in advocacy, grant writing, program develop- ment, and grassroots community involvement needed by psychologists to perform prevention work (Bluestein, Goodyear, Perry, & Cypers, 2005). It could also include training on the ecological prevention approach espoused by the field of social work (Kriste-Ashman, 2000).

    SOCIAL AND POLITICAL ADVOCACY

    This domain is made up of Guidelines 13–15, which are equally as criti- cal because they call for psychologists to step out of their traditional roles and engage in political processes in order to improve the world in which they live. Many decisions affecting physical/mental health care are made on the basis of political considerations, rather than on scientific or educational merit. Whether because of insecurity, disinterest, or disdain, it is tempting for psychologists to leave this work to others, not recognizing that psychol- ogists are the experts in behavior change. The skills psychologists possess

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    could be applied to any arena in which behavior change is warranted, including but not limited to the political process as well as the more traditional areas of schools, health care, violence prevention, and so forth. Psychologists need to become part of solving these serious social problems facing our country and world (Albee, 1986). Unfortunately, these are exactly the areas in which our efforts may be most controversial and, thus, uncomfortable for our profession.

    WHERE DO WE GO FROM HERE?

    Although these guidelines provide an overarching set of best practices, they fall short in that they do not provide the necessary information for “how to” do this work. These guidelines are broadly stated and therefore may not provide the direction or structure a psychologist may need in order to become competent in prevention work. Nevertheless, the guidelines serve as the springboard for further investigation into how the field of psy- chology will actually train, cultivate, and develop psychologists who will engage in proactive, socially just prevention work.

    The choice to have a clinical and a counseling psychologist as well as a social worker respond to this article was purposeful. Clearly, each of us brings a unique experience and set of skills that are needed to begin to address the serious societal problems facing our country and our world. We must work together as professional disciplines, sharing our skill sets, lessons learned, and methodology to bring about real social change. As eloquently argued by Hage et al. (2007), prevention work needs to be at the forefront of a comprehensive mental health agenda (p. 494). We would argue, however, that the term prevention may need to be expanded in order for this to occur. Prevention is often juxtaposed with remediation, as if they were dichotomous constructs. It is our premise that prevention and remediation lie on a continuum, with group-based interventions occupying a space somewhere in between.

    We would argue that prevention should be viewed as one of the tools on the continuum of therapeutic/treatment services and that the paradigm shift should consist of the acknowledgement that some of what we are labeling as prevention could actually be considered therapeutic interventions that are empirically based, well grounded in theory, and developed from a thor- ough assessment of need (Nation et al., 2003). For example, the first author (a clinical psychologist), along with her training director and fellow coun- seling psychology interns, while on their American Psychological Association internship at the University of Akron’s Testing and Career Center, developed a grassroots career and college preparation program called Latinos on the Path to Higher Education (Rivera-Mosquera, Phillips, Castelano, Martin, &

    590 THE COUNSELING PSYCHOLOGIST / July 2007

    Mowry, 2007). The goals of the program were to reduce the dropout rate and improve the college entrance of Latino youths—both serious societal problems facing the United States. The interns, utilized the first author’s strong clinical assessment and treatment skills, in addition to the counsel- ing psychology interns strong career development and educational preven- tion skills, to design and implement the program in a local Hispanic church. Most of the students recruited for this program could have been treated individually by any number of disciplines within psychology in an office environment, and the therapist could have secured third-party payment based on issues of learning/academic difficulties. The difference was that insurance covered interventions provided under the individual remedial model and not under the prevention model. It is our premise that prevention programs that are grounded on clinical and counseling theories of psycho- logical behavioral change are actually psychotherapeutic in nature and, thus, should be called psychotherapeutic prevention programs that could be reimbursed as treatment interventions by third-party payers.

    The question then becomes: How do psychotherapeutic prevention pro- grams differ from group therapy? The goal of group therapy is, of course, for the group process to facilitate behavior change in the individuals in that group. This is also true for psychotherapeutic prevention. Perhaps the pri- mary difference is the targeted audience. Psychotherapeutic prevention pro- grams are generally larger in scope, may address more issues simultaneously, and usually reach a larger audience. We propose that well-researched and well-designed psychotherapeutic prevention programs be viewed as a form of group therapy and, thus, be considered as psychological treatment interven- tions. Viewing prevention as a treatment tool opens the doors for innovative programs to be developed and funded that may not only prevent symptoms from developing in targeted populations but could also provide a group ther- apeutic process to change behavior on a larger scale.

    There are several skills that psychologists will need to develop in order to conduct prevention work, particularly when working with difficult-to-reach communities such as ethnic minorities. First and foremost, psychologists need to develop a strong personal relationship with the targeted community. The success of the Latinos on the Path to Higher Education program was based primarily on the quality of the relationship between the first author and the community. We recommend that psychologists and other mental health providers go out into the community and cultivate these essential relation- ships of trust early on in their training so that the stage will be set for program development later. Professors and students must venture out of the “ivory towers” and into the community (churches, mental health clinics, and social service agencies) to explore and experience the social environment and issues surrounding them. Ethically, psychologists should not develop prevention

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    programs if they have not ever ventured into or experienced firsthand the community in which they plan to research or work.

    In addition to developing a trusting relationship, psychologists will also need to cultivate a number of other skills such as advocacy, program develop- ment, grant writing, cultural competence/cultural humility, social justice, and qualitative and quantitative evaluation skills—just to name a few (Romano & Hage, 2000). Unfortunately, these skills are not necessarily taught in tradi- tional psychology programs, not even at the doctoral level. Psychology pro- grams should embrace a cross-disciplinary model and allow students to take courses in other fields that focus on systemic change and/or advocacy such as social work, public health, nursing, anthropology, and forth. Training models such as the one used in the Latinos on the Path to Higher Education program could be readily taught and integrated into doctoral training programs. The program benefited all of those involved because the youths and their parents obtained a set of self-efficacy skills, and the interns had an enriched training experience that enhanced their skills in the area of community engagement, outreach, advocacy, and cultural competence. In addition, models of training such as the two pedagogical strategies (service learning and problem-based learning), which Hage et al. (2007) discuss in their article, could be quite effective in teaching psychotherapeutic prevention models in psychology courses (p. 539). The authors even include a mock syllabus for one of the strategies, making it easier for instructors to develop a prevention course. Throughout their article, Hage et al. offer practical advice and exposure to practical prevention research, which can be quite useful to psychologists seeking to engage in prevention work.

    CONCLUSION

    Hage et al. (2007) have provided a valuable service to the field of psychol- ogy by providing a set of guidelines that can be used as a springboard for fur- ther research and development in the field of prevention. Undoubtedly, an increased emphasis on prevention will require that the field cultivate psychol- ogists who are community-oriented and committed to social justice as well as to political advocacy so that psychotherapeutic prevention programs may flourish. Students of psychology must be exposed to important issues faced by American society early in their training. Practical experiences with marginal- ized individuals such as ethnic and cultural minorities, the hearing impaired, lesbian/gay/bisexual/transgender groups, and others are needed so that stu- dents can begin their training on psychotherapeutic prevention development and programming. Psychology students should first understand and acquiesce to the social justice model as well as develop an empathic connection with the

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    movement of marginalized groups or affected societal segments before they can effectively develop, plan for, and engage in psychotherapeutic prevention work. Psychology students also need to volunteer and become active in the tar- geted group in order to develop a strong relationship of trust with that com- munity. This relationship is the cornerstone for the effective delivery of prevention work. Psychology departments, as well as placement and intern- ship sites, must make a concerted effort to not only integrate prevention into their curriculums but also to help students connect to and engage in experien- tial learning in the targeted communities. In addition, psychologists need to become active and lobby for the funding of psychotherapeutic prevention pro- grams as treatment interventions. Fortunately, the President’s New Freedom Commission, which President George W. Bush established in 2002, seems to be leading the charge for establishing prevention as a viable treatment tool in the arena of mental health. This prevention-focused paradigm shift may have finally begun to take root.

    REFERENCES

    Albee, G. W. (1986). Toward a just society: Lessons from observations on the primary pre- vention of psychopathology. American Psychologist, 41, 891-898.

    Bloom, M. (1996). Primary prevention practices. Thousand Oaks, CA: Sage. Blustein, D. L., Goodyear, R. K., Perry, J. C., & Cypers, S. (2005). The shifting sands of coun-

    seling psychology programs’ institutional contexts: An environmental scan and revitaliz- ing strategies. The Counseling Psychologist, 33, 610-634.

    Hage, S. M., Romano, J. L., Conyne, R. K., Kenny, M., Matthews, C., Schwartz, J. P., & Waldo, M. (2007). Best practice guidelines on prevention practice, research, training, and social advocacy for psychologists. The Counseling Psychologist, 35, 493-566.

    Kirst-Ashman, K. (2000). Human behavior, communities, organizations and groups in the macro environment (pp. 19-25). Belmont, CA: Brooks/Cole.

    Nation, M., Crusto, C., Wandersman, A., Kumpfer, K., Seybolt, D., Morrissey-Kane, E., & Davino, K. (2003). What works in prevention: Principles and effective prevention pro- grams. American Psychologist, 58, 449-546.

    National Association of Social Workers. (2003–2006). Social work speaks. Washington, DC: Author.

    Reese, L., & Vera, E. M. (in press). Culturally relevant prevention: Scientific and practical considerations of community-based programs. The Counseling Psychologist, 35.

    Rivera-Mosquera, E. T., Phillips, J., Castelano, P., Martin, J., & Mowry, E. (in press). Design and implementation of a grassroots pre-college program for Latino youth. The Counseling Psychologist, 35.

    Romano, J. L., & Hage, S. M. (2000). Prevention and counseling psychology: Revitalizing commitments to the 21st century. The Counseling Psychologist, 28, 733-763.

    Waldo, M., & Schwartz, J. P. (2003, August). Research competencies in prevention. Paper pre- sented at the Prevention Competencies Symposium at the 111th Annual Convention of the American Psychological Association, Toronto, Ontario, Canada.

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    Towards a Cultural–Clinical Psychology

    Andrew G. Ryder1,2*, Lauren M. Ban1,2 and Yulia E. Chentsova-Dutton3 1 Concordia University 2 Sir Mortimer B. Davis-Jewish General Hospital 3 Georgetown University

    Abstract

    For decades, clinical psychologists have catalogued cultural group differences in symptom presenta- tion, assessment, and treatment outcomes. We know that ‘culture matters’ in mental health – but do we know how it matters, or why? Answers may be found in an integration of cultural and clinical psychology. Cultural psychology demands a move beyond description to explanation of group variation. For its part, clinical psychology insists on the importance of individual people, while also extending the range of human variation. Cultural–clinical psychology integrates these approaches, opening up new lines of inquiry. The central assumption of this interdisciplinary field is that culture, mind, and brain constitute one another as a multi-level dynamic system in which no level is primary, and that psychopathology is an emergent property of that system. We illustrate cultural–clinical psychology research using our work on depression in Chinese populations and conclude with a call for greater collaboration among researchers in this field.

    Horace Cho1 is a 57-year-old businessman from Hong Kong who has resided in Vancouver for fif- teen years, referred for insomnia, fatigue, loss of appetite, gastrointestinal distress, and depressed mood. Mr. Cho was raised in Hong Kong, completed his MBA in California, and moved to Van- couver to join his wife’s family and start a new business. Despite Mr. Cho’s excellent English and knowledge of North American practices, his business is in difficulty. He attributes business troubles to the effects of his physical symptoms, rather than seeing these symptoms as resulting from psychoso- cial stress.

    Mr. Cho lives in a majority Chinese suburb and encourages his children to stay close to Chinese traditions; however, his daughters desire greater participation in North American society. He describes his wife as much more traditional than he is, but to his surprise it is she who encourages the children to participate in mainstream society. At the initial interview, Mr. Cho denies depressed mood but agrees that symptoms, business difficulties, and values conflicts in his family are ‘upsetting some- times’.

    What is Mr. Cho’s ‘culture’, and is it the same as his wife’s? Does he have a mental health problem and, if so, what is it? In what ways does culture shape the experience, expression, and communication of his distress? Where can psychologists look for ways to think about such questions?

    Over the past few decades, scholars from several disciplines have examined the interrela- tion of culture and mental health. Many more have taken on cross-cultural comparisons in mainstream psychology. That ‘culture matters’ in clinical psychology is nothing new, although it bears frequent repetition in an era of biological reductionism. Rather, our claim is threefold: first, that there is relatively little cultural research in clinical psychology that aspires to explanation, to telling a culturally-framed story about what is observed; second, that the means for achieving this can be found in greater integration of cultural and clinical

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    psychology, to the benefit of both; and third, that the result is a new field. Cultural–clinical psychology has in some sense been around for a while, pursued by a small number of researchers. Nonetheless, it has not yet coalesced as an established field of study or as an approach to culture and mental health research. This paper aims to promote these ends.

    We start by locating ourselves with respect to ‘cultural psychology’ and ‘clinical psy- chology’, and then present some first steps toward a cultural–clinical psychology. Central to this integration is the idea of mutual constitution – that culture, mind, and brain form a single system in which no level can be understood without the others. We then draw on our own research, pertaining to depression in Chinese populations, to provide some empirical examples. We conclude with a brief critique of these studies, considering ways in which they could be improved and interpreted in light of cultural–clinical psychology. Concrete suggestions to improve cultural–clinical psychology research are summarized in the Appendix and referenced throughout.

    Cultural–Clinical Psychology: A Brief Introduction

    Cultural psychology

    In positioning cultural–clinical psychology, we begin by grounding the first term in the ‘cultural psychology’ perspective (e.g., Markus & Kitayama, 1991; Shweder, 1990). The word ‘culture’ has long been used in psychology to stand for ethnicity or nationality, and invoked as a black-box explanation: groups differ because of ‘culture’, but the specific ways in which this happens remain unclear. Cultural psychology represents a move away from cataloguing differences to understanding culture and how it shapes psychological variation (e.g., Betancourt & López, 1993; Cohen, Nisbett, Bowdle, & Schwarz, 1996; Heine and Norenzayan, 2006; Kitayama, Markus, Matsumoto, & Norasakkunkit, 1997). Differentiating between culture and ‘cultural group’ emphasizes that individual group members can partially adhere to or reject aspects of culture. For example, Mr. Cho and his wife have different views about the acculturation of their children, and not in ways that are obviously predictable from their own degree of traditionalism (Appendix: 1.1).

    Is culture best understood as ‘in the head’ or ‘in the world’? These views are held in tension and they sometimes conflict but, as with cognition and behavior in clinical psy- chology, neither is sufficient alone. People do not simply carry out behaviors. Rather, they perform ‘acts of meaning’ (Bruner, 1990), intended by the actor and understood by observers as meaningful. These acts are framed by the cultural meaning system and their enactment contributes to shaping this system (Kashima, 2000). Nisbett and Cohen (1996), for example, conducted an important series of studies on the ‘Culture of Honor’ in the American South, reporting that southerners have more favorable attitudes towards vio- lence in cases where honor is at stake. Moreover, they demonstrated experimentally that southerners whose honor has been challenged are more physiologically reactive and take longer to step out the way of a confederate walking toward them in a narrow corridor. Cultural variation is captured here by both opinions and behaviors, and the behaviors of both participant and confederate are understood as meaningful.

    The idea of cultural scripts can bridge these perspectives, as they both reflect meaning structures in the head and guide behavioral practices in the world (DiMaggio, 1997). Scripts refer to organized units of knowledge that encode and propagate meanings and practices. They serve as mechanisms that allow for rapid automatic retrieval and use of information acquired from the world while shaping how that information is perceived. Enacted as behavior, scripts are observable to others and become part of the cultural

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    context, shaping assumptions about what others think and expectancies about how they will behave (Chiu, Gelfand, Yamagishi, Shteynberg, & Wan, 2010). Moreover, people can access multiple cultural scripts, primed by different contextual cues (Hong & Chiu, 2001). If while at home Mr. Cho scolds his children for pursuing a ‘Western lifestyle’, he is accessing available scripts for cultural preservation while his actions and others’ responses contribute to shaping these scripts, and passing them to his children. In work contexts, these same scripts may be primed rarely if at all. Mr. Cho’s wife can understand him according to their shared meaning system even as she accesses a different available cultural script – promoting her children’s well-being by ensuring they can function in a new society (Appendix: 2.2).

    Clinical psychology

    In using the term ‘clinical’ in cultural–clinical psychology, we are thinking primarily of researchers trained as scientists or scientist-practitioners in clinical psychology, health psy- chology, or experimental psychopathology. Although not all of these researchers are directly engaged with both science and practice, there is an emphasis on moving between theory and research about groups on the one hand, and the experiences and needs of individual sufferers on the other. Clinical psychology is concerned both with describing pathological phenomena and with using psychological principles to intervene with these phenomena therapeutically.

    As a health discipline, clinical psychology inevitably discusses ‘symptoms’ and ‘syn- dromes’ – specific pathological experiences and the ways in which they are grouped. Mr. Cho’s reported symptoms are insomnia, fatigue, loss of appetite, and gastrointestinal dis- tress, with some evidence of depressed mood. A clinician trained in DSM-IV has over 300 syndromes to consider, but would most likely consider Major Depressive Disorder (MDD). Clinical psychology has long had a certain willingness to critique diagnostic sys- tems accompanied by a preference for evidence-based symptom dimensions (Achenbach & Edelbrock, 1983; Krueger & Markon, 2006). This openness benefits cultural studies of psychopathology, as diagnostic systems are themselves cultural products (Gone & Kirma- yer, 2010; Lewis-Fernández & Kleinman, 1994). Moreover, Kleinman (1988) argues that rigid application of a diagnostic system conceals cultural variation. He has shown how The International Pilot Study of Schizophrenia reliably identified patients meeting diag- nostic criteria for schizophrenia, but in doing so eliminated a large proportion of psy- chotic patients at each site – precisely those patients who showed the most variability across the cultural groups (Appendix: 1.2).

    Cultural–clinical psychology: what’s new?

    In an era both of fragmentation and interdisciplinarity in psychology (Cacioppo, 2007) it is easy to argue that two areas can benefit from collaboration on topics of shared concern. We wish to make a stronger claim in this case: a new field emerges at their intersection. For this to be plausible, we must first establish that clinical psychology is altered by con- sideration of cultural questions. More challenging, we must also establish that cultural psychology is altered by clinical questions, not simply given new content. Research in cultural–clinical psychology should tell us something new about the cultural contexts under study, not just the pathologies. Finally, we must demonstrate that new questions and methods for addressing them emerge from this sub-discipline, or at least that the potential is there (Appendix 2.1).

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    Clinical psychology encounters cultural psychology. A central issue for clinical psychology – what is disorder? – cannot be fully understood without considering deep cultural influ- ence. The oft-used distinction between illness and disease defines illness as the socially-sit- uated experience of having a particular disorder and disease as the corresponding malfunction in biological or psychological processes (Boorse, 1975; Kleinman, 1977). Wakefield (1992) similarly defines disorder as harmful dysfunction, in which harm indi- cates that the disorder is problematic in a given cultural context and dysfunction indicates the failure of a biological system evolutionarily adapted for particular ends.

    While these approaches ostensibly give equal credit to culture and biology, uncritical acceptance plays into biases of mainstream clinical psychology. Researchers can end up exemplifying Geertz’s (1984, p. 269) characterization of the behavioral sciences, in which, ‘‘culture is icing, biology, cake…difference is shallow, likeness, deep’’. We prefer to see disorder as both biological and cultural, in a fundamentally inseparable way. Depressed mood has many biological and cultural constituents worthy of focused study for specific purposes, but there is no depressed mood until these constituents come together and are experienced by someone.

    Methodologically, clinical research has much to gain from incorporating the cultural psychology perspective. Integration of findings on the cultural shaping of psychological functioning can allow clinical psychologists to develop a broader and more nuanced view of normal human experience. Cultural psychology is well positioned to help clinical psy- chology move beyond conceptualizations of mental illnesses as products of solitary minds to thinking of it as contextually embedded in networks of local meanings, norms, institu- tions, and cultural products (e.g., Adams, Salter, Pickett, Kurtis, & Phillips, 2010). Finally, cultural psychology can inform our understanding of the ways in which people, including both patients and clinicians, incorporate contextual information in detecting, reporting and interpreting symptoms of mental illness (for examples of these cultural psychology ideas, not yet adapted for clinical questions, see Heine, Lehman, Markus, & Kitayama, 1999; Hong, Morris, Chiu, & Benet-Martı́nez, 2000; Masuda & Nisbett, 2001; Uchida, Norasakkunkit, & Kitayama, 2004. In Mr. Cho’s case, the institutional demands of a mental health clinic may have tilted the emphasis toward symptoms and attributions and away from the understandable suffering caused by business and family difficulties (Appen- dix: 2.3).

    The idea of scripts can help us think about specific ways in which mental health is shaped by cultural context. Although by definition abnormality violates expectations of what is normal, people nonetheless have scripts to help them make sense of pathology as best they can. Confusing and frightening experiences, such as emerging psychopathology, have a particularly strong need for scripts (Philippot & Rimé, 1997; Taylor, 1983). The large but finite number of ways to be physically or psychologically distressed is further molded by cultural-historical context, so that specific disorders draw upon a pool of avail- able symptoms (Shorter, 1992). Cultural scripts can then be seen as mapping the sufferer’s experience to what is available in this ‘symptom pool’, focusing on and thereby amplify- ing those symptoms that best serve explanatory and communicative purposes. Denial of depressed mood and acknowledgement that his problems are upsetting can be seen as serving Mr. Cho’s communication goals in a particular health care setting.

    Cultural psychology encounters clinical psychology. Beyond providing new content, potential contributions of clinical psychology begin with two of cultural psychology’s core concerns: heterogeneity of cultural groups and limited coherence of cultural contexts (Kashima, 2000). These concerns do not necessarily require clinical psychology, but the

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    study of mental disorder serves as an engine to generate many examples of each. Psycho- pathological phenomena also shed new light on culture; as with the lesion studies that propelled neuroscience, we learn new things about cultural processes when the normal cultural scripts no longer work (For a similar idea, not specific to psychopathology, see Beckstead, Cabell, & Valsiner, 2009). North American studies of social phobia patients highlight the central role fear of negative evaluation plays when healthy interpersonal func- tioning breaks down (see Hofmann & Barlow, 2002). These findings also reveal some of the assumptions of normal social relationships in North America: one is to portray one’s true self and have it be positively evaluated by others. Studies of socially anxious patients in other cultural groups can serve the same function, showing for example how fear of caus- ing discomfort to others – perhaps by inappropriately revealing one’s true self – is a central concern for many socially anxious people in East Asian contexts (Rector, Kocovski, & Ryder, 2006; Sasaki & Tanno, 2005; Zhang, Yu, Draguns, Zhang, & Tang, 2000).

    Methodologically, clinical psychology has a rich tradition of modeling ways in which abnormal behavior is shaped by constraints imparted by physiological and environmental influences, and their interactions. For example, contemporary research on depression spans multiple levels of analysis ranging from genes to hormones, brain anatomy and function, attention, memory, emotional reactivity, personality, and interpersonal function- ing (Hammen, 2003; for a thorough review, see chapters in Gotlib & Hammen, 2009). Clinical psychology can also provide tools for theorizing about the ways in which psy- chological processes become functional or dysfunctional in a cultural context. For exam- ple, cultural innovation and propagation depends on specific abilities, such as harnessing novel associations or conveying negative emotions (Chentsova-Dutton & Heath, 2007), that are also associated with predisposition to certain forms of psychopathology.

    Cultural–clinical psychology: mutual constitution of culture–mind–brain

    The core claim of cultural psychology is not simply that groups differ or ‘culture matters’, but rather that human culture and human psychology are each grounded in the other: that culture and mind ‘make each other up’ (Shweder, 1991). Clinical psychology research, in keeping with trends in psychological science and in psychiatry, tends to focus more on the interrelation of mind and brain (Andreasen, 1997; Barrett, 2009; Ilardi & Feldman, 2001). We argue that the best approach for cultural–clinical psychology emerges from the joint concerns of the two fields, leading us to discuss mutual constitution of cul- ture, mind, and brain. This approach follows recent trends in cultural psychiatry (Kirma- yer, forthcoming) and cultural psychology (Chiao, 2009; Kitayama & Park, 2010; Kitayama & Uskul, 2011), in which culture, mind, and brain are thought of as multiple levels of a single system, here called the culture–mind–brain (Appendix: 3.1).

    Culture and mind. The mutual constitution of culture and mind develops through pro- cesses that are an integral part of socialization, in that minds develop in cultural contexts that are themselves composed of minds (Cole, 1996; Valsiner, 1989). We cannot under- stand human minds unless we understand them in cultural context, and we cannot under- stand human culture unless we understand minds. The goal is to find ways of thinking and studying the psychological and the cultural so that neither is seen as the ultimate source of the other (Markus & Hamedani, 2006; Shweder, 1995).

    Mind and brain. It is increasingly untenable to propose models of mental health that have no room for the brain, as shaped by the genome and in turn by evolutionary processes.

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    While we agree wholeheartedly with Geertz (1973) that, ‘‘it is culture all the way down’’, we also simultaneously make the opposite claim: it is biology all the way up. Both must be true for mutual constitution to have any meaning. Rather than seeing mind as the subjective epiphenomenon of brain, however, we prefer a view of mind as funda- mentally social and tool-using, even as extended beyond the brain (Clark & Chalmers, 1998; Hutchins, 1995; Kirmayer, forthcoming; Vygotsky, 1978). Habitually used tools and close others are partially incorporated into one’s mind: the online calendar can become part of the mind’s memory system; the close friend can become part of the mind’s emotion regulation system.

    Culture and brain. It does not necessarily follow from a tripartite model of culture, mind, and brain in this way that mind mediates all culture-brain links. The human brain is adapted to acquire culture and responds to cultural inputs with marked plasticity, espe- cially early in development (Wexler, 2006). Indeed, the emergence of a recognizable human mind may require these transactions between culture and brain. At the same time, biology constrains culture. There are a large number of possible ways in which culture can be configured, yet the number of impossible configurations is practically infinite (Gil- bert, 2002; Mealey, 2005; Öhman & Mineka, 2001). That this is true does not compro- mise the equally important observation that human possibilities are many, diverse, and deeply shaped by culture (Marsella & Yamada, 2010; Tseng, 2006).

    The ecology of culture–mind–brain. Describing the interrelations of culture, mind, and brain as a triangle of linked associations might imply three interrelated systems. We prefer to think of culture–mind–brain as one dynamic multilevel system, an information network instantiated in neuronal pathways, cognitive schemata, human relationships, culturally- mediated tools, global telecommunications, corporations, political actors, health care sys- tems, and so on. Cultures, minds, and brains cannot be understood in isolation from one another. As yet, there is little research that engages with all three levels simultaneously, although a promising avenue has been opened by Kim, Sherman, Taylor, et al. (2010a). These researchers showed that cultural context and variations in certain serotonin recep- tor genes interact to predict locus of attention. Specifically, one of the variants predicts a tendency to attend to context in Korean participants, and the same variant predicts an especially strong tendency to attend to the focal object in Euro-American participants.

    Psychopathology is an emergent property of culture–mind–brain, with no ultimate cause at any one level. While changes at one level affect all levels, it does not follow that disorder at one level means disorder at other levels, let alone that disorder at a higher level must be caused by disorder at a lower level. A disordered brain circuit does not require malfunctioning neurons, nor does a disordered neuron require malfunctioning molecules, although neither makes sense in the absence of neurons or molecules. Pathol- ogy can emerge from problematic feedback loops in which the response to a problem exacerbates the problem, even when all components of the loop are working normally (Hacking, 1995; Kirmayer, forthcoming). A conditioned fear that goes on to cause prob- lems in living is a disorder, it involves the brain, but it does not require a disordered brain. Values conflict between Mr. Cho and his wife can create a stressful environment for their children, but not because a lower-level disorder leads them to adhere to patho- logical values.

    Disorder at higher levels can also lead to disorder at lower levels. Cultural norms, eco- nomic conditions, and political response might interact to produce violent conflict, with consequences that include damage to brains from traumatic stress. It is incomplete at best

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    to claim that psychological consequences of that damage are caused by the brain without acknowledging political or economic causes. Similarly, Mr. Cho’s depression might make sense as psychosocial stress coupled with preexisting vulnerability, but the depression has lasting consequences for the brain (Kendler, Thornton, & Gardner, 2000). A mind-level intervention such as Cognitive-Behavior Therapy (CBT), moreover, impacts on the brain (DeRubeis, Siegle, & Hollon, 2008) – unsurprising, as culture–mind–brain is a single system (Appendix: 3.2).

    Before considering an example of three recent cultural–clinical psychology lines of research focused on an interrelated set of questions, let us briefly return to the case of Mr. Cho.

    After the initial assessment, Mr. Cho began a 16-week course of CBT for depression. The case at first appeared to be a textbook case of ‘Chinese somatization’; somatic symptoms were discussed almost exclusively, unlinked to psychosocial stressors. Sustained discussion of these stressors would sometimes lead to marked tearfulness and inability to maintain emotional compo- sure. Once rapport was established, depressed mood was acknowledged fairly quickly, along with guilt and pessimism, primarily described as reactions to how the physical symptoms had impacted his business and family life.

    Mr. Cho asked several times how CBT could help him with his primary concern – the somatic symptoms – and as treatment turned to depressed mood, guilt, and pessimism, he began to miss ses- sions. We reframed treatment in line with CBT approaches to Chronic Fatigue Syndrome – empha- sizing holism of mind and body, talking more openly about somatic symptoms, and incorporating some somatic approaches such as sleep hygiene and diet regulation. Psychological and physical causes, psychological and physical symptoms, all became legitimate topics for discussion.

    Cultural–Clinical Psychology: Empirical Examples

    We are each involved in independently developed lines of research taking a cultural psy- chology approach to clinically-relevant questions about Chinese-origin participants and depression. To illustrate the potential of cultural–clinical psychology, we turn to a more sustained discussion of this work.

    Cultural psychology research on depression

    Somatic and psychological symptoms. In a now classic study, Kleinman (1982) argued that Chinese psychiatric patients tend to emphasize somatic symptoms relative to ‘Western’ norms (see also Parker, Cheah, & Roy, 2001). Ryder et al. (2008) used multiple assess- ment methods with Han Chinese and Euro-Canadian psychiatric outpatients. Results generally showed greater somatic symptom reporting in the Chinese group and greater psychological symptom reporting in the Euro-Canadian group. The tendency to devalue the importance of one’s emotional life was also higher in the Chinese group and medi- ated the relation between cultural group and symptom presentation.

    Devaluation of one’s emotional life does not fit well with readily accessible cultural scripts in North America. This tendency was measured using a tool designed to mea- sure pathology, the Externally-Oriented Thinking (EOT) subscale of the Twenty-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994). Whereas EOT might capture pathological beliefs in a cultural context that fosters ideals of healthy emotional expression, it may simply represent adherence to an accessible cultural script in Chinese contexts (see Dion, 1996; Kirmayer, 1987). In a comparison of Chinese- and Euro-Canadians, group difference in EOT was mediated by adherence to

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    ‘Western’ values (Dere, Falk, & Ryder, forthcoming). People vary in accessibility of cultural scripts about emotional expression, and cultural contexts vary in terms of how normal these scripts are perceived to be. Mr. Cho had access to multiple scripts but the Chinese somatic script predominated – he emphasized somatic symptoms while increasingly considering psychological symptoms, and tended to see the latter as conse- quences of somatic symptoms.

    Emotional expression. Studies comparing depressed Euro-Americans and Asian-Americans to their non-depressed counterparts show that depression is associated with culturally-spe- cific patterns of emotional reactivity. For Euro-Americans, depression is characterized by dampened emotional reactivity in response to positive and negative emotional films (see Bylsma, Morris, & Rottenberg, 2008). Chentsova-Dutton et al. (2007) replicated this pattern with negative films in Euro-Americans using self-report, facial coding, and physiological measures, but failed to find it – and at times, found the inverse – in Asian- Americans (primarily Chinese-Americans). More surprisingly, Chentsova-Dutton, Tsai, and Gotlib (2010) replicated the pattern using positive films, so that on certain measures such as cardiac reactivity, depressed Asian-Americans were actually more reactive than non-depressed Asian-Americans.

    Cultural contexts provide people with shared scripts for how to feel and express emo- tions. Failure to enact culturally normative emotional scripts may contribute to depressed mood, and may also be exacerbated by such mood. The Euro-American pattern of damp- ened reactivity when depressed may reflect failure to enact accessible cultural scripts for open and prominently displayed emotional responses (Bellah, Sullivan, Tipton, Swidler, & Madsen, 1985). The Chinese-American pattern of heightened reactivity when depressed may reflect failure to enact readily available cultural scripts of moderated expe- rience and expression of one’s emotions (Russell & Yik, 1996). Exemplifying the latter, Mr. Cho was at times strikingly expressive discussing difficult topics despite retrospec- tively denying depressed mood.

    Explanatory models. It is normative in ‘Western’ cultural settings to not just emphasize psychological symptoms but also to link distress to psychological causes. Ban, Kashima, and Haslam (2010) explored the extent to which behavior is deemed pathological if it violates this cultural script. A vignette describing someone with depression, including or not including a psychological cause, was presented to Euro-Australian and Chinese-Sin- gaporean university students. Euro-Australian students were more likely to perceive depression as ‘normal’ when their vignette included a psychological explanation. For Chinese-Singaporean students, psychological explanations made the depression seem less normal, and they preferred moral to psychological explanations on a questionnaire.

    For Euro-Australians, living in a cultural context with a readily accessible script equat- ing abnormality with irrational psychological functioning, psychological explanations help restore a sense of order. Chinese-Singaporeans, by contrast, live in a cultural context where the predominant script equates emotional maturity with adjustment of behavior to situational demands (Kirmayer, 2007). Indeed, Chinese-Singaporean moral explanations centered on failed social obligations. These modes of explanation represent scripts that are available, to varying extents, in different cultural contexts. Mr. Cho initially presented along the lines of a medicalizing script, which soon gave way to a moralizing script about failing his family. Eventually, he was willing to consider a psychologizing script without fully endorsing it.

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    Reinterpreting the research

    How can we understand these findings in light of culture–mind–brain? Before depression emerges, people have access to culturally shaped scripts about what depression is and assume others have access to these scripts as well (Ban et al., 2010). Once depression emerges, its implications cascade rapidly through all levels of culture–mind–brain, moti- vating people to make sense of what is happening to them (Philippot & Rimé, 1997). Scripts focus attention on certain symptoms, magnifying some experiences and minimiz- ing others. A looping effect takes place – experiences that best draw upon the cultural symptom pool in ways that fit available scripts about depression are focused upon, further contributing to their severity (Shorter, 1992). Multiple cultural scripts can coexist and draw upon this pool, so that patients in a single cultural context can nonetheless present many different kinds of symptoms (Ryder et al., 2008).

    In keeping with the idea of mind as social, we have real and imagined audiences for this process: what do we tell other people; what are they going to notice; how are they going to react? (Chiu et al., 2010) These others are specific others, with their own expe- riences, relationships with the sufferer, social roles, and functions within societal institu- tions. The real and imagined presence of specific others shapes the explanations chosen, the emotions expressed, and the symptoms emphasized (Chentsova-Dutton & Tsai, 2010; Jakobs, Manstead, & Fisher, 1996; Lam, Marra, & Salzinger, 2005; Matsumoto, Takeuchi, Andayani, Kouznetsova, & Krupp, 1998). Sufferers generate additional stressors as others react to evident and unusual signs. It is not simply that depression is associated with non- normal emotional expressions (Chentsova-Dutton et al., 2007, 2010), but that another loop is generated where reactions of others to these expressions lead to censure and with- drawal, hence to rejection and further depression.

    As per the cultural dynamical approach (Kashima, 2000), we should expect actual experiences of depression – what is experienced, expressed, talked about, witnessed, shared with mental health professionals, discussed in the local community – to shape cul- tural scripts pertaining to depression. There is emerging evidence in China that rapid social change is shifting public understanding of depression, altering cultural scripts, and in turn shaping symptoms presented by successive cohorts. In consequence, exposure to modernization and Westernization values is lessening the tendency for Chinese patients to emphasize somatic symptoms of depression (Ryder et al., forthcoming).

    Contributions and limitations

    These studies represent three independent attempts to bring together cultural and clinical psychology to investigate a particular clinical phenomenon in a particular cultural group, drawing on both fields for theory, methodology, and interpretation. These studies go beyond cataloguing group differences, examining how various aspects of Chinese – and ‘Western’ – cultural contexts, including scripts, values, cognitive styles, norms, and attri- butions, shape depression. They are methodologically varied, including self-report ques- tionnaires but also interviews, open-ended response coding, psychophysiology, facial coding, vignettes, mediation analysis, and experimental designs.

    Our studies have limitations, notably including failures to adhere to some of the rec- ommendations summarized in the Appendix. Cultural and diagnostic groups, for example, could be more clearly defined. The studies are compatible with a dynamic view of culture but do not go very far in advancing that agenda. Culture is not assessed in a multi-method way. More fundamentally, however, what is missing so far is the brain,

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    and thus the potential synthesis implied by culture–mind–brain. Somatic and emotional experiences are connected in the brain (Craig, 2008) and may be emphasized or deem- phasized in the mind based on cultural scripts (Wiens, 2005). Kim, Sherman, Sasaki, et al. (2010b) have shown that variations in oxytocin receptor genes interact with cultural con- text and level of subjective distress to predict help-seeking, a rare example of how levels of culture–mind–brain can be included in a single study.

    Even with improvements in conception, sampling, methods, and interpretation, we do not expect that any given study, or even research program, would cover everything dis- cussed here. Cultural–clinical psychology already exists in a sense, including researchers who have been making important contributions for years. At the same time, there is as yet little sense of a shared enterprise, let alone of the institutional markers of such. What is needed is a greater degree of coherence and integration, where individual research groups approach different pieces of the overall puzzle, but with a shared framework and an ongoing commitment to putting this puzzle together.

    Conclusion

    There is much to be gained from greater connection between cultural and clinical psy- chology, with a core of researchers at the intersection. Cultural psychology can benefit from testing the limits of cultural influence across the full range of psychological func- tioning, including psychopathological extremes and difficult environmental conditions. Likewise, clinical psychology can consider a wider range of sociocultural phenomena that may affect mental illness. The two fields together point to a dynamic model of culture– mind–brain that can serve as a central pillar of this interdisciplinary field. Cultural–clinical psychology advances attempts to conceptualize mental health phenomena as dynamic and context-dependent, rather than fully reducible to physiological deficits or environmental stressors. We emphasize ‘cultural’ aspects because we believe that explanations at this level are often neglected in mental health research, but hope that ultimately no discussion of mental health will seem complete without consideration of all levels.

    The case of Mr. Cho illustrates how knowledge of cultural context and its accessible symptom scripts help us to better assess clients and modify treatment approaches to better adapt to these scripts. We observe how the clinical encounter becomes a space in which cultural scripts are negotiated, influencing both participants and shifting over the course of treatment. Training programs, internship sites, and licensing bodies increasingly insist on training in diversity and cultural competence without a clear vision of how to proceed or what evidence to use. Cultural competence is more than simply using good clinical skills with ethnic minority patients; cultural–clinical psychology can aspire to provide an evidence base (Ryder & Dere, 2010). At the same time, cultural competence includes questioning that evidence, considering dangers of reducing people to cultural categories (Kleinman & Benson, 2006). As we conclude our case history, we catch a glimpse of how seeing a patient’s symptoms only through the lens of cultural explanations can yield surprises.

    By the end of treatment, Mr. Cho was still struggling but wanted to try implementing some changes by himself. He continued to prioritize somatic symptoms, but agreed that psychological symptoms were part of his experience. At six-month follow-up, Mr. Cho reported ongoing appetite and gastrointestinal problems, but much better sleep, energy level, and mood. He mentioned that he was now working with a specialist, who was finding that the ongoing gastrointestinal and appetite problems might be related to a specific medical issue. The possibility of this separate issue may have been lost in the context of the other symptoms.

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    Acknowledgment

    Preparation of this manuscript was supported by a New Investigator Award from the Canadian Institutes of Health Research to AGR. The authors gratefully acknowledge the comments provided by Emily Butler, Jessica Dere, Marina Doucerain, Alan Fiske, MarYam Hamedani, Nick Haslam, Steve Heine, Tomas Jurcik, Yoshi Kashima, Laurence Kirmayer, Michael Lorber, Andrea McCarthy, Vinai Norasakkunkit, Nicole Stephens, and Romin Tafarodi on earlier versions of this manuscript.

    Short Biographies

    Andrew G. Ryder received his doctorate in psychology (clinical) from the University of British Columbia and currently directs the Culture, Health, and Personality Lab in the Department of Psychology at Concordia University, where he holds the position of Asso- ciate Professor. He is also an adjunct faculty member in the Culture and Mental Health Research Unit at the Sir Mortimer B. Davis–Jewish General Hospital in Montreal. Dr. Ryder’s research lies at the intersection of cultural, clinical, and personality psychology. Most of his published work combines at least two of these areas, including papers in Jour- nal of Abnormal Psychology, Harvard Review of Psychiatry, Journal of Affective Disorders, Journal of Personality and Social Psychology, and Journal of Personality Disorders. Current research focuses on: (a) the intersection of cultural and personality variables in shaping depressive symptom presentation in China and South Korea; and (b) acculturation and adaptation in complex multicultural societies. His work is supported by a New Investigator Award from the Canadian Institutes for Health Research (CIHR) and grants from CIHR and the Fonds de la recherche en santé du Québec.

    Lauren M. Ban received her doctoral degree in psychology (social) from the University of Melbourne. At time of writing she was a postdoctoral fellow in the Department of Psy- chology at Concordia University and the Culture and Mental Health Research Unit at the Sir Mortimer B. Davis–Jewish General Hospital in Montreal, under the supervision of Dr. Ryder and Dr. Laurence Kirmayer. Her dissertation research explored folk perceptions of mental disorder comparing people with East Asian (primarily Chinese–Singaporean) and European–Australian cultural backgrounds, and a study from this work has been published in the Journal of Cross-Cultural Psychology. Current research takes a cultural psychology per- spective on self-construals, explanatory models of mental illness and internalized stigma.

    Yulia E. Chentsova-Dutton received her master’s degree (clinical science and psycho- pathology) from the University of Minnesota and her doctoral degree (affective science) from Stanford University. She holds the position of assistant professor in the Department of Psychology at Georgetown University in Washington, D.C., where she directs the Culture and Emotion Lab. Her research spans cultural psychology, emotions, and mental health, and her publications include papers in the Journal of Abnormal Psychology, Journal of Personality and Social Psychology, and Cultural Diversity and Ethnic Minority Psychology. Her specific research interests include the cultural shaping of: (a) emotions, including concep- tions and functions of emotions, emotional reactivity, and interoception); and (b) social support, including advice-giving and support networks. Her work is supported by the Social Psychology Program of the National Science Foundation.

    Endnotes

    * Correspondence address: PY153-2, 7141 Sherbrooke St. W., Montreal, Quebec, H4B 1R6, Canada. Email: andrew.ryder@concordia.ca

    1 Horace Cho is based on a composite of two cases. Identifying information has been fictionalized.

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    Appendix: Practical recommendations for conducting cultural–clinical psychology research

    1. Defining cultural and diagnostic categories. When we use categories, we have a tendency to assume that these categories are clearly separated from one another and capture fundamental differences. We essentialize groups when we assume that all people

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    from a certain cultural background or carrying a certain diagnosis are the same as one another, and different from people in other groups. At the same time, however, it is very difficult to conduct research without relying on groupings of individual people. Research- ers should therefore adopt a pragmatic rather than essentialized approach to describing cultural groups and diagnostic categories:

    1.1. For cultural groups, specify on a study-by-study basis how each group is defined and for what purposes, and interpret results in light of a more nuanced and dynamic view of culture. Doing so not only means more accurate reporting of methods, but also serves as a reminder that group membership is not self-evident, especially around the edges of a given category.

    1.2. For diagnostic categories, consider a ‘lumping’ approach for syndromes and a ‘splitting’ approach for symptoms – very few broad categories for communication and comparison purposes (e.g., emotional disorders, psychotic disorders) followed by a fine-grained approach to individual symptoms. We might define the problem being compared across groups very broadly – for example, how do people in different context cope with loss? – and then seek to answer that question in part by looking at differences in how individual symptoms are presented.

    2. Understanding and measuring culture. Culture is complex, deeply intercon- nected with all aspects of human life, often implicit, rarely straightforward, and can shape different people in different ways. It is therefore difficult to study, and it is hard to conduct good research without already knowing a lot about the context being studied – much as mainstream psychology researchers have a lot of tacit and unexamined knowledge about their own contexts. Researchers should therefore know the cultural context well, aided by personal immersion in the context, selected cultural informants, and ⁄ or multicultural research teams:

    2.1. Tell a cultural story about the phenomena under study, aiming to explain ways in which culture shapes mental health rather than cataloguing group differences. At the start of a line of inquiry, that should involve using knowledge of the cultural context to propose potential explanations. Later on, studies should incorporate these potential explanations into the research design; for example, by testing the extent to which they can mediate group difference effects, or by manipulating them experimentally.

    2.2. Pay attention to and assess contradictory cultural scripts, rather than assuming that cultural contexts foster a single script for a particular domain. Doing so helps move away from cultural determinism and helps counteract the tendency to essentialize culture, serv- ing as a reminder that culture is complex and can influence different people in different ways.

    2.3. Aim to measure culture in a multi-method way, as it exists in the head (e.g., via self-report or implicit cognitive tasks) and in the world (e.g., via behavioral observation or examination of cultural products). While not always possible within a single study, use of different methods strengthens a line of research and captures some of the complexity of culture. Indeed, it is not always the case that these different methods will agree; points of contradiction may be important.

    3. Situating research within the culture-mind-brain system. We have described culture, mind, and brain as a deeply interactive and non-reductive multilevel system. It is not possible to capture such a system within a single study, or even in a line of research. What is possible, however, is to focus on aspects that are important to the research question and compatible with one’s training and resources. These aspects should be iden-

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    tified and studied carefully while we remain mindful that our work is embedded within a broader system. Researchers should therefore remember that a complex and dynamic system requires one to enter at a certain point, chosen for reasons of practicality or training:

    3.1. Use culture–mind–brain as the overarching framework, clearly delineating a cer- tain part of the system within a study for pragmatic research purposes. A more narrowly- defined study (e.g., described by the methods and results) can be framed within a broader conceptual argument (e.g., described by the introduction and discussion). A series of more specific empirical papers can be supported by a more general theoretical review.

    3.2. Given that one is focusing on part of the system, frame causal arguments as proxi- mal rather than ultimate. It is unlikely that one has identified a causal explanation for anything that itself has no need of explanation. This does not take away from the possi- bility that we might have identified a crucial link in the causal chain, or the importance of doing so.

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    Copyright of Social & Personality Psychology Compass is the property of Wiley-Blackwell and its content may

    not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written

    permission. However, users may print, download, or email articles for individual use.

    •• Rejoinder

    Walking the Talk: Implementing the Prevention Guidelines and Transforming the Profession of Psychology

    Sally M. Hage Teachers College, Columbia University

    John L. Romano University of Minnesota, Twin Cities

    Robert K. Conyne University of Cincinnati

    Maureen Kenny Boston College

    Jonathan P. Schwartz University of Houston

    Michael Waldo New Mexico State University

    The Major Contribution aimed at strengthening a prevention focus in psychology, so as to more effectively and equitably promote the well-being of all members of psychology com- munities. The 3 reactions (L. A. Bond & A. Carmola Hauf, 2007 [this issue]; L. Reese, 2007 [this issue]; E. Rivera-Mosquera, E. T. Dowd, & M. Mitchell-Blanks 2007 [this issue]) give strong support for the best practice prevention guidelines, while providing new insights for their implementation in the field of psychology. In this rejoinder, the authors make an effort to build upon their colleagues’ ideas, by addressing the topics of community-based collaboration, prevention across the life span, and implementation of the best practice guidelines. The authors urge further interdisciplinary collaboration by members of the American Psychological Association, and others interested in prevention, and invite genuine action to expand prevention efforts.

    Undoubtedly, the expression—“You can talk the talk, but can you walk the walk?”—is familiar to many people. A shortened variation of the orig- inal phrase, “Walk the talk,” may be less well known but can be found in the Encarta World English Online Dictionary (2006), and is defined as “to act on what you profess to believe in or value.” The words suggest that real

    After the first two authors listed above, the remaining authors of this article are listed in alpha- betical order. Correspondence concerning this article should addressed to Sally M. Hage, Teachers College, Columbia University, Counseling and Clinical Psychology Department, Box 102, 426A Horace Mann, New York, NY 10027; e-mail: hage@tc.columbia.edu.

    THE COUNSELING PSYCHOLOGIST, Vol. 35, No. 4, July 2007 594-604 DOI: 10.1177/0011000006297158 © 2007 by the Division of Counseling Psychology

    594

    change happens when leaders not only say they want change and advance- ment but also match their words with actions. We are grateful to the authors who provided reactions to our article (Bond & Carmola Hauf, 2007 [this issue]; Reese, 2007 [this issue]; Rivera-Mosquera, Dowd, & Mitchell-Blanks, 2007 [this issue]). Their thoughtful commentary and suggestions highlight the importance of moving these Prevention Guidelines (Hage et al., 2007 [this issue]) from a publication in a scholarly journal to genuine actions for change in the field of psychology. We are also grateful to The Counseling Psychologist (TCP) Editor Robert T. Carter who gave us the opportunity to develop the article into a Major Contribution manuscript, and to receive reactions to these guidelines by eminent scholars in the field.

    The reaction articles in this Major Contribution include authors from specialties in social work, clinical psychology, and counseling psychology. In addition, they represent work settings as diverse as university psychol- ogy departments, a government mental health department, a community advocacy agency, and a medical school. The work of prevention is multi- disciplinary, and it is critically important that researchers, practitioners, and policy makers from across the professional landscape collaborate and form partnerships to advance a prevention agenda. We are extremely pleased and honored that these scholars, from different specialties and professional work environments, have given their reactions to the guidelines. In the lim- ited space in this rejoinder, we will address several of the issues presented by the reaction articles.

    COMMUNITY-BASED COLLABORATION

    Bond and Carmola Hauf (2007), Reese (2007), and Rivera-Mosquera et al. (2007) all identified the importance of collaboration as a central com- ponent of best practices in prevention. Although our guidelines did not explicitly address collaboration, our third practice guideline emphasizes the importance of including “clients and other relevant stakeholders in all aspects of prevention planning and programming” and thus recognizes the necessity of forming community partnerships in prevention work (p. 508). That being said, the reactants did a service by further emphasizing the importance of collaboration as an integral component of best practices at several levels. All three reaction articles note that the perspectives and knowledge base of any single profession are limited in informing and guiding the practice of prevention. Indeed, these authors collectively describe why collaboration should occur at the local community level, with other helping professionals, and with scholars and researchers from other disciplines.

    Hage et al. / WALKING THE TALK 595

    Bond and Carmola Hauf (2007) maintain that interdisciplinary scholar- ship should provide the theory and research base for effective prevention. They effectively explain how community collaboration is critical to the development of comprehensive and multisystemic interventions. In addi- tion, Rivera-Mosquera et al. (2007) advocate for collaboration across the health and mental health professions, including counseling and clinical psy- chologists, social workers, nurses, and public health workers. Reese (2007) similarly notes that the knowledge base of multiple disciplines, such as epi- demiology, health, economics, and sociology, are integral to public health practice and prevention. By insulating ourselves from other disciplines and professions, we are likely to miss important research knowledge. Similarly, by cutting ourselves off from the communities we serve, we may miss an understanding of local needs and knowledge. Furthermore, from a training perspective, learning the art of collaboration represents an example of an area where even more “how to” guidance is needed. Some authors (e.g., Kenny, Sparks, & Jackson, in press) are documenting their work in collab- oration in efforts to identify lessons to further guide training and practice in interprofessional collaboration. Developing and sustaining effective collab- orations with multiple stakeholders and then negotiating and reconciling the competing needs represented by varied perspectives are challenging tasks.

    Similarly, as Bond and Carmola Hauf (2007) suggest, community-based collaboration enables more accurate and relevant prevention research. One potential function of Waldo and Schwartz’s (2003) prevention research matrix presented in this issue is to point out how diverse sources of exper- tise available through community and interdisciplinary collaboration can be integrated to conduct comprehensive prevention research. For example, community members can provide unique information on the epidemiology of problems within their community; they can inform the design of preven- tive interventions, ensuring they are targeted on the most salient variables and are sensitive to community norms; and they can identify the systems and resources within a community that will allow wide and sustained deliv- ery of prevention services.

    The expertise of different disciplines may also make unique contribu- tions in each of these service areas. For example, the field of public health is especially suited to clarifying epidemiology, clinical psychology is strong in the design and evaluation of interventions, and the social work profession is adept at creation and assessment of service delivery systems. Rivera-Moquera et al. (2007) eloquently state that “each of us brings a unique experience and set of skills that are needed to begin to address the serious societal problems facing our country and our world” (p. 590). Hence, the diverse communities and professional disciplines must work

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    together in “sharing our skill sets, lessons learned, and methodology to bring about real social change” (Rivera-Mosquera et al., 2007, p. 590).

    Nevertheless, in spite of our strong agreement with all three of the reac- tants that collaborative community partnerships are critically important to the work of prevention specialists, we are reluctant to identify the forming of such partnerships as the “overarching best practice” of prevention. The major reason for our hesitation to adopt this perspective, as argued by Bond and Carmola Hauf (2007), is that “community” is too often interpreted nar- rowly. A framework of “community” may not give sufficient visibility to educational training of psychologists or political advocacy for prevention. As Rivera-Mosquera et al. (2007) comment, the four conceptual areas of the guidelines, which include practice, research, training, and social advo- cacy, provide a necessary conceptual framework. In addition, a community is not a single voice and may, for example, include parents, teachers, busi- nesses, workers, social services agency leaders, clergy, and youths. In addi- tion to a divergence in voices emanating from the field, these voices may not be congruent with those from multiple professions and scholarly disci- plines. Thus, although better practice may eventually emerge, the processes through which this happens are not always clear. Indeed, Bond and Carmola Hauf (2007) recognize the tensions that often exist when preven- tionists attempt to apply prevention interventions across diverse groups of people.

    One method to address specific needs across divergent groups or to assess in-group differences is through a process called “elicitation research” (Flores, Tschann, & Marin, 2002). This research process collects informa- tion during the development phase of a prevention intervention to better understand relevant personal cognitions and social norms important to a group or population receiving the intervention, thus strengthening the rele- vancy of the intervention for those receiving it. Conducting elicitation research prior to finalizing a prevention intervention increases the chances of a successful outcome for behavior change by addressing variables impor- tant to the group being served. Romano and Netland (in press) demonstrated how elicitation research and the theory of reasoned action (Ajzen & Fishbein, 1980; Albarracin, Fishbein, Johnson, & Muellerleile, 2001) can address within-group differences in the development and implementation of prevention interventions.

    PREVENTION ACROSS THE LIFE SPAN

    Reese (2007) notes that many of the examples of prevention interventions provided in our set of Prevention Guidelines were drawn from practice with

    Hage et al. / WALKING THE TALK 597

    young people, despite the fact that prevention theory and practice cut across the life span. We concur with Reese on his point and hope that our examples of effective interventions with youths do not lead readers to think of pre- vention as an activity only for the early years. Prevention is not only for chil- dren and adolescents but also must be applied throughout the life cycle, including the development of preventative interventions for diverse groups of women and men at midlife and communities of older adults. Indeed, developmental challenges, risks, and opportunities for positive development occur across the life span, and these many stages of life represent significant opportunities for prevention-minded psychologists to engage in active col- laborative efforts across the disciplines. It is possible that many of our examples emerge from youth work because schools and colleges have been available settings for prevention interventions, and they also offer opportu- nities for funding of prevention research. As we move to increase the reality of prevention across the life span, we will need to find mechanisms to fund and house prevention activities for all phases of life.

    There are indications that the field of psychology is increasing its atten- tion to the unique needs of older adults. For example, interventions have addressed the prevention of suicide and depression in older adults (Heisel & Duberstein, 2005; Whyte & Rovner, 2006). In addition, the American Psychological Association (APA) Public Interest Directorate has estab- lished an Office on Aging, which coordinates APA activities pertaining to aging and geropsychology. The Office on Aging also supports the work of the APA Committee on Aging, which has published a handbook on psy- chology and aging (American Psychological Association Committee on Aging, 2006). This work recognizes that not only are people 65 years of age and older the fastest growing segment of the U.S. population, with an increasing number of these older adults of immigrant status or members of ethnic or racial minority groups, but that more than 5 million older adults have incomes below the poverty level or are classified as poor. Adulthood is also a period of life where adults confront a variety of changes related to families, interpersonal relationships, careers, health, and end-of-life issues. Prevention has a role to play in helping adults manage and prevent the adverse effects of these changes.

    Hence, we welcome Reese’s (2007) reminder to “cast a broad net” in the goal of expanding our prevention efforts. He insightfully challenges psychol- ogists to more effectively address the interface of physical and mental health, and reminds us of the imperative to decrease health disparities and improve the quality of life of communities in the United States and abroad. His remarks reflect the social justice orientation out of which the Prevention Guidelines emerge. This perspective demands that we become aware of how the numer- ous systems that are part of U.S. society, including economic, governmental,

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    and educational structures, define truth for the entire community (Dounce, 2004; Dworkin & Yi, 2003). Prevention work can and should begin within the local context (e.g., to apply the social justice model in our own communities) but also needs to be thoughtfully concerned with systemic practices and the state of power and oppression around the globe. Our efforts must aim to enhance personal and collective well-being and to create social and political change aimed at improving environments where people live, learn, and work (Hage, 2005).

    Similarly, we endorse Bond and Carmola Hauf’s (2007) recognition of the importance of moving beyond a focus on strengths and protective factors at the individual level, to also address such strengths at multiple systemic levels (e.g., microsystem, organizations and institutions, community, sociopolitical, cultural–environmental). While strength-based models related to individuals have received attention in the literature, there is much less focus on strengths and protective factors of communities, organizations, and institutions. Hence, it is important to consider the strengths, as well as the limitations, of institu- tions, such as schools, cultural centers, faith communities, and community organizations, when planning and implementing prevention interventions.

    IMPLEMENTATION OF THE PREVENTION GUIDELINES

    In their reaction articles, Rivera-Mosquera et al. (2007) and Reese (2007) recognize the significance of moving beyond the “ivory tower” and the level of “rhetoric” to make the Best Practices Prevention Guidelines a reality. Similarly, Bond and Carmola Hauf (2007) remind us that prevention review articles of this nature have been presented in other professional journals, with remarkably similar conclusions. We would like to recognize the validity of these concerns, while also providing further explanation of the process of development of these guidelines. Members of the Prevention Section of Division 17 developed these Prevention Guidelines with the goal of eventu- ally bringing them forth for adoption by APA and other professional organi- zations and government entities, as suggested by Reese (2007). Therefore, the Prevention Guidelines were formulated in accordance with Criteria for Practice Guideline Development and Evaluation, developed by APA in 1995 and later revised and approved by the APA Council of Representatives (American Psychological Association, 2002). The APA criteria specify that proposed guidelines, such as those presented in our article, need to focus on educating and informing the practice of psychologists, as well as stimulating debate and research. As such, the APA document specifies that guidelines “must be reasonable, well researched, aspirational in language, and appropri- ate in goals” (Section 1.1). Hence, the specificity of these requirements meant

    Hage et al. / WALKING THE TALK 599

    that content related to the implementation of the Prevention Guidelines was mostly left out of our article. However, despite this limitation, the Prevention Guidelines are the first set of comprehensive prevention guidelines that encompass the major areas of prevention work (i.e., practice, research, train- ing, and social advocacy) that have been prepared for eventual adoption by APA. Finally, as noted in our article, these guidelines are an “initial step” in what we hope will be a broader collaboration of psychologists working together to enhance and implement these recommendations for prevention within the Society of Counseling Psychology, other appropriate APA divi- sions, as well as APA and other professional organizations.

    We share the concern voiced by Rivera-Mosquera et al. (2007): If further efforts beyond the publishing of these guidelines are not made, this work may likely “fail to provide forceful guidance for significant change” (p. 587). Hence, while the guidelines may be recognized, as Reese (2007) notes, as a “next step” in stimulating counseling psychologists to engage in prevention, they represent just one step, and further discourse on implemen- tation and process is essential to move prevention more visibly from the fringes of the field to center stage in the profession. Similar comments were made by two past presidents of Division 17, Rosie Bingham and Derald Wing Sue, at the 2006 APA Symposium addressing the implications of these guidelines (Hage & Romano, 2006). In their presentations, Bingham and Sue drew comparisons between the Prevention Guidelines and the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (American Psychological Association, 2003) in terms of their movement from an academic article to implementation and action. In summary, the challenge for prevention spe- cialists as well as the larger community of scholars and practitioners is to develop creative ways to advance a prevention agenda, and we hope that these Guidelines provide guidance.

    We appreciate the specific recommendations put forth by the reactants for how best to advance the dissemination of the Prevention Guidelines, and would like to highlight some of their suggestions. Education and training, both at the pre- and the postdoctoral levels, was cited as one essential area for implementation. We strongly concur with Rivera-Mosquera et al. (2007) and with Reese (2007) in their recommendation that prevention theory, research, and practice need to be included within counseling psychology curricula at all levels. The challenge that demands further attention is how we move forward to infuse prevention practice and research not only in counseling psychology training but also throughout psychology education.

    Reese’s (2007) suggestion that the Prevention Guidelines become part of “any reading packet for courses on prevention” is well taken, as is the rec- ommendation to include implementation of the Prevention Guidelines on the

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    Hage et al. / WALKING THE TALK 601

    agenda for discussion at the annual meeting of the Council of Counseling Psychology Training Programs. We would also suggest that the guidelines be included in the training of doctoral students and be discussed by other psychology training groups (e.g., Council of School Psychology Training Programs). Reese also suggests partnerships with professional organizations outside of psychology (e.g., public health), government entities (e.g., U.S. Department of Health and Human Services), and stakeholders in the com- munity. We would add other academic disciplines (e.g., social work, coun- seling) as well as accreditation bodies such as the APA’s Committee on Accreditation, the Council for Accreditation of Counseling and Related Educational Programs, and psychology as well as other mental health licens- ing boards to the list of disciplines and partnering organizations. Moreover, Rivera-Mosquera et al. (2007) note the importance of addressing the ethics of prevention. This need has begun to be addressed, although not as broadly as we would like (e.g., Hage & Schwartz, 2006; Schwartz & Hage, in press). Prevention practica are also urgently needed, as Reese (2007) suggests. Finally, developing the equivalents of “preventive medical residency pro- grams” for counseling psychologists, as well as pre- and postdoctoral intern- ships in prevention research and practice, are excellent suggestions that deserve careful consideration.

    In addition, one of the most innovative ideas for dissemination of these guidelines comes from Rivera-Mosquera et al. (2007), who point out that the economics of prevention has been a major obstacle in furthering prevention efforts. Their unique contribution is the suggestion that preventive services be viewed as a type of therapeutic program. They argue that by conceptualizing prevention as a “therapeutic intervention,” new avenues to support the work of prevention (e.g., third-party reimbursement) may emerge. By extension, if third-party reimbursement were to become possible for prevention, then the place of prevention in psychology education and training programs will be more fully secured. This perspective is an interesting one to consider and mer- its close attention and further discussion among scholars, practitioners, and pol- icy makers. However, it may be more effective to develop financial models that can prove the cost-effectiveness of prevention, rather than compromising the conceptualization of prevention. For example, several recent studies have found that teaching clients interventions based on cognitive–behavioral therapy is cost-effective in preventing the onset of a full-blown depressive disorder (Churchill et al., 2001; McCrone et al., 2004; Schulberg, Raue, & Rollman, 2002; Smit et al., 2006). The dissemination of more findings like these studies on depression is critical in convincing policy makers and funding organizations that prevention is cost-effective.

    Reese (2007) issues a similar call for prevention research that is relevant, disseminated, and utilized. We agree that too much good prevention research

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    remains academic, and thus fails to realize its potential to improve lives, particularly in communities disadvantaged by disparities in resources. We believe that including a focus on service delivery systems as an integral com- ponent of programmatic prevention research has significant potential for cor- recting this deficit. For example, we recommend that investigators examine the practical utility and economic feasibility of their research by utilizing the prevention research matrix presented in this issue, and by examining how a research project relates to the third category—Prevention Service Delivery Systems. The prevention research matrix provides a tool to understand the need for research and how the outcome of this research can inform the field. Understanding this process will often lead to more open and informed com- munication with participating communities about the meaning and scope of the prevention program at each step of the intervention.

    CONCLUDING OBSERVATION

    A final observation we would like to make is to underline the significance of the reaction articles being intentionally authored by a clinical psychologist, a counseling psychologist, and a social worker. This effort by TCP represents an excellent attempt at reflecting an important reality about prevention: It is an interdisciplinary science and practice that requires interdependent collab- oration in order to be effective. We need more efforts like this one, includ- ing applications to education and training in prevention. In addition, Reese (2007) provides a valuable perspective as a counseling psychologist who pre- viously was employed by the Centers for Disease Control and Prevention, and currently is in the Department of Community Health and Preventive Medicine, Morehouse School of Medicine. He observes that psychology must move prevention more forcefully from the margins of the field to the heart of the profession, and that the Society of Counseling Psychology ought to take the lead for all of psychology in making this transformation happen. We whole-heartedly agree with this perspective, and we invite psychologists and others interested in prevention to join this effort by becoming involved in the Prevention Section (http://www.div17.org/preventionsection).

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    604 THE COUNSELING PSYCHOLOGIST / July 2007

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