Literature Review

See 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 all attached.Clinical and counseling psychology is a dynamic field that is constantly evolving and striving toward better treatment options and modalities. In this literature review, 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 the review, include the following headings, and address the required content.(1)Assessment:Support this section with information from the Ryder et al. (2011) article “Towards a Cultural-Clinical Psychology” and at least one additional scholarly peer-reviewed article(a)Compare the assessments currently in use by clinical and counseling psychologists(b)Explain the trend towards cultural-clinical psychology and the suitability of clinical assessments with diverse clients(2)Clinical work:Support this section using a minimum of three scholarly peer-reviewed articles. The recommended articles attached may be useful in generating the response in addition to the three scholarly peer-reviewed articles(a)Compare and contrast technical eclecticism, assimilative integration and theoretical integration(b)Provide a historical context and identify the major theorists for each perspective(c)Assess the trends in psychotherapy integration(d)List three pros and cons for each perspective, sharing which perspective most closely aligns with your own(e)Analyze the major trends in psychology and explain the connection between evidenced-based practices and psychotherapy integration(3)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(a)Describe general prevention strategies implemented by clinical and counseling psychologists at the micro, meso, exo, and macro levels?

Guidelines for Prevention in Psychology. (2014). American Psychologist, 69(3), 285–296. https://doi.org/10.1037/a0034569.

Hage, S. M., Romano, J. L., Conyne, R. K., Kenny, M., Schwartz, J. P., & Waldo, M. (2007). Walking the talk: Implementing the prevention guidelines and transforming the profession of psychology. The Counseling Psychologist, 35(4), 594-604. doi:10.1177/0011000006297158.

Rivera-Mosquera, E., Dowd, E. T., & Mitchell-Blanks, M. (2007). Prevention activities in professional psychology: A reaction to the prevention guidelines. The Counseling Psychologist, 35(4), 586-593. doi:10.1177/0011000006296160.

Ryder, A. G., Ban, L. M., & Chentsova-Dutton, Y. E. (2011). Towards a cultural-clinical psychology. Social & Personality Psychology Compass, 5(12), 960-975. doi:10.1111/j.1751-9004.2011.00404.x

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.

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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

588 THE COUNSELING PSYCHOLOGIST / July 2007

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

Rivera-Mosquera et al. / PREVENTION GUIDELINES 589

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

Rivera-Mosquera et al. / PREVENTION GUIDELINES 591

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

592 THE COUNSELING PSYCHOLOGIST / July 2007

Rivera-Mosquera et al. / PREVENTION GUIDELINES 593

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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•• 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.

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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

596 THE COUNSELING PSYCHOLOGIST / July 2007

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,

598 THE COUNSELING PSYCHOLOGIST / July 2007

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

600 THE COUNSELING PSYCHOLOGIST / July 2007

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

602 THE COUNSELING PSYCHOLOGIST / July 2007

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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Guidelines for Prevention in Psychology

American Psychological Association

The effectiveness of prevention to enhance human func-
tioning and reduce psychological distress has been demon-
strated (Catalano, Berglund, Ryan, Lonczak, & Hawkins,
2002; Greenberg, Domitrovich, & Bumbarger, 2001; Na-
tional Research Council & Institute of Medicine, 2009).
Successful preventive interventions are typically theory
driven, culturally relevant, developmentally appropriate,
and delivered across multiple contexts (Nation et al., 2003).
Preventive services and interventions help to further the
health and well-being of individuals, communities, and
nations (Satcher, 2000; World Health Organization, 2008).
Expanding preventive services reduces the costs of mental
health care (Tolan & Dodge, 2005), while emerging tech-
nological innovations (e.g., telehealth) offer promise for
preventive interventions (Bull, 2011; Chinman, Tremain,
Imm, & Wandersman, 2009).

From infancy through adulthood, access to preventive
services and interventions is important to improve the
quality of life and human functioning and reduce illness
and premature death (Grunberg & Klein, 2009; Konnert,
Gatz, & Hertzsprung, 1999). Prevention has typically taken
a developmental approach, focusing on children and ado-
lescents, in order to facilitate trajectories leading to positive
outcomes (National Research Council & Institute of Med-
icine, 2009). Children and adolescents are at significant risk
for substance abuse, violence, and sexually transmitted
infections, and their access to quality health services is
limited (Centers for Disease Control and Prevention, 2007;
Weissberg, Walberg, O’Brien, & Kuster, 2003). Thus, nor-
mal development may be impeded at large costs to society,
and additional strains imposed on families. In any given
year, 14%–20% of children and adolescents experience a
mental, emotional, or behavioral disorder (National Re-
search Council & Institute of Medicine, 2009). In addition,
national surveys show that the majority of youth who could
potentially benefit from mental health services do not re-
ceive services (Ringel & Sturm, 2001). Early and focused
interventions can limit the length and severity of symptoms
and enhance functioning (Cicchetti & Toth, 1992; Durlak,
Weissberg, & Pachan, 2010). Prevention also includes the
collaborative design and delivery of strengths-based health
promotion and environmental improvement strategies (e.g.,
Cowen, 1985). Health promotion approaches equip people
with life skills and coping competencies, such as problem-
solving skills, contributing to their capacity to live more
fully while being better able to withstand future stressful
life events.

Preventive services and interventions also address is-
sues of health, educational, and social inequities that reflect
disparities across demographic groups such as those based
on race, gender, and socioeconomic class. Environmental

improvement prevention strategies, such as consultation to
improve community–family–school coordination or inter-
ventions to help communities create well-paying jobs, aim
to inform social policy, which can minimize or eliminate
factors contributing to unhealthy functioning.

The importance of prevention is consistent with the
Patient Protection and Affordable Care Act (2010), which
calls for expansion of preventive services to maximize
positive health outcomes, as well as with the U.S. National
Prevention Strategy (National Prevention Council, 2011),
which “provides an unprecedented opportunity to shift the
nation from a focus on sickness and disease to one based on
wellness and prevention” (National Prevention, Health Pro-
motion, and Public Health Council, 2011, p. 1) throughout
the life span. Several disciplines other than psychology
have been historically and currently active in prevention
(e.g., public health, social work). However, beginning in
the mid-20th century with the field of community psychol-
ogy, psychology began to play an increasingly important
role (e.g., Eby, Chin, Rollock, Schwartz, & Worell, 2011).
Even with the increased focus on prevention, psychology
training programs rarely require specific courses on pre-
vention (O’Neil & Britner, 2009). In particular, conceptu-
alizations about best practices in prevention, particularly at
the environmental level, are lacking (Snyder & Elliott,
2005). In addition, the Ethical Principles of Psychologists
and Code of Conduct (American Psychological Associa-
tion [APA], 2010) do not fully address unique ethical
issues that may arise in prevention (e.g., Schwartz & Hage,
2009). Therefore, psychologists engaged in prevention can
benefit from a set of guidelines that address and inform
prevention practices.

This article was published Online First November 4, 2013.
These guidelines were approved by the American Psychological Associ-
ation (APA) Council of Representatives in February 2013. The guidelines
were developed by APA’s Prevention Guidelines Work Group. The Work
Group members, listed alphabetically after the chair, included John L.
Romano (chair), G. Anne Bogat, Robert K. Conyne, Sally M. Hage,
Arthur M. Horne, Maureen E. Kenny, Connie Matthews, Jonathan P.
Schwartz, Anneliese Singh, Michael Waldo, and Y. Joel Wong.

The Work Group wishes to acknowledge and thank many groups,
committees, and organizations, including APA’s Board of Professional
Affairs and Committee on Professional Practice and Standards, as well as
individuals too numerous to list here, who contributed to the development
of the Prevention Guidelines during the review process and comment
periods.

This document is scheduled to expire as APA policy in February
2020. After this date, users are encouraged to contact the APA Practice
Directorate to confirm that this document remains in effect.

Correspondence concerning this article should be addressed to the
Practice Directorate, American Psychological Association, 750 First
Street, NE, Washington, DC 20002-4242.

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285April 2014 ● American Psychologist
© 2013 American Psychological Association 0003-066X/14/$12.00
Vol. 69, No. 3, 285–296 DOI: 10.1037/a0034569

http://dx.doi.org/10.1037/a0034569

Purpose
APA (2002, p. 1050) refers to guidelines as

statements that suggest or recommend specific professional be-
havior, endeavors, or conduct for psychologists. Guidelines differ
from standards in that standards are mandatory and may be
accompanied by an enforcement mechanism . . .. guidelines are
aspirational . . . intended to facilitate the continued systematic
development of the profession and to help assure a high level of
professional practice . . .. Guidelines are not intended to be man-
datory or exhaustive and may not be applicable to every profes-
sional and clinical situation. They are not definitive and they are
not intended to take precedence over the judgment of
psychologists.

Accordingly, the Guidelines for Prevention in Psychology
(cited as Prevention Guidelines or Guidelines for the re-
mainder of this document) are intended to “inform psychol-
ogists, the public, and other interested parties regarding
desirable professional practices” (APA, 2002, p. 1049) in
prevention.

The Prevention Guidelines are, in part, practice guide-
lines and different from treatment guidelines as defined by
APA (2002). The Guidelines are recommended for the
practice of psychology across areas that engage psycholo-
gists. The Guidelines are consistent with federal and state
laws and regulations. In the event of a conflict between the
Guidelines and any federal or state law or regulation, the
law or regulation in question supersedes these Guidelines.
Psychologists are encouraged to use their education and
skills to resolve any conflicts in a way that best conforms
to both law and ethical practice. The Guidelines are con-
sistent with the Ethical Principles of Psychologists and
Code of Conduct (APA, 2010), particularly Principles D
(justice) and E (respect for people’s rights and dignity).

Background
APA convention symposia (Hage & Romano, 2006;
Kenny, 2003; Romano, 2002) initiated the development of
these Guidelines, followed by an article describing preven-
tion best practices (Hage et al., 2007). These Guidelines
were later introduced as new business for the APA Council
of Representatives, whereupon they underwent significant
review, including APA governance and public comment
periods, in accordance with Association policy relevant to
guidelines (APA, 2013, Association Rule 30-8). The
Guidelines were approved by the APA Board of Directors
in December 2012 and by the APA Council of Represen-
tatives in February 2013.

Definitions
Prevention has been conceptualized as including one or
more of the following: (a) stopping a problem behavior
from ever occurring; (b) delaying the onset of a problem
behavior, especially for those at-risk for the problem; (c)
reducing the impact of a problem behavior; (d) strengthen-
ing knowledge, attitudes, and behaviors that promote emo-
tional and physical well-being; and (e) promoting institu-
tional, community, and government policies that further
physical, social, and emotional well-being of the larger

community (Romano & Hage, 2000). This conceptualiza-
tion is consistent with Caplan’s (1964) definition that iden-
tified prevention interventions as primary, secondary, and
tertiary prevention, and with the definition by Gordon
(1987) that identified prevention interventions as universal,
selected, and indicated for those not at risk, at risk, and
experiencing early signs of problems, respectively. Gor-
don’s conceptualization was adopted by the Institute of
Medicine (1994). A follow-up report from the Institute of
Medicine broadened this universal, selective, and indicated
framework to include “the promotion of mental health”
(National Research Council & Institute of Medicine, 2009,
p. 65).

Throughout this document, the terms prevention, pre-
ventive intervention(s), preventive program(s), and preven-
tive services are used. Activities subsumed by these rubrics
could focus on any of the five aspects of prevention in-
cluded in the Romano and Hage (2000) conceptualization
of prevention. Although space precludes a thorough exe-
gesis of all types of programs, decisions about how and
when to intervene might lead to different outcomes, differ-
ent ancillary effects, and different ways of approaching
issues within cultures and settings.

Documentation of Need
The Prevention Guidelines are recommended based on
their potential benefits to the public and the professional
practice of psychology. The Guidelines support prevention
as an important area of practice, research, and training for
psychologists. The Guidelines give increased attention to
prevention within APA, encouraging psychologists to be-
come involved with preventive activities relevant to their
area of practice.

The National Research Council and Institute of Med-
icine’s (2009) Committee on the Prevention of Mental
Disorders and Substance Abuse Among Children, Youth
and Young Adults: Research Advances and Promising In-
terventions stated, “Infusing a prevention focus into the
public consciousness requires development of a shared
public vision and attention at a higher national level than
currently exists” (p. 5). The Guidelines provide added
visibility to the importance of prevention across profes-
sional practice areas and among the public. The Guidelines
also support the U.S. Department of Health and Human
Services’ calls for health promotion and prevention in its
Healthy People publications outlining national health goals
(e.g., U.S. Department of Health and Human Services,
2000). Healthy People 2020 (U.S. Department of Health
and Human Services, 2010) continues the tradition of ear-
lier publications by setting goals to eliminate preventable
disease, achieve health equity, eliminate health disparities,
create social and physical environments to promote good
health, and promote healthy development and healthy be-
haviors across the life span. Other U.S. government bodies
have also emphasized the importance of prevention to the
overall health and well-being of the population (Mrazek,
2002).

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286 April 2014 ● American Psychologist

The Patient Protection and Affordable Care Act
(2010) includes preventive services as an important com-
ponent of overall health care. The legislation strives to
make wellness and preventive services affordable and ac-
cessible by requiring health plans to cover preventive ser-
vices without copayments. These services include counsel-
ing to improve habits of lifestyle (e.g., proper nutrition,
weight management), counseling to reduce depression, and
preventive services to foster healthy birth outcomes.

The contributions and leadership of psychologists are
critical in implementing a prevention focus in the health
care system. Evidence increasingly suggests that mental
illness, such as depression, is linked to chronic health
issues such as heart disease and diabetes (Volgelzangs et
al., 2008). Therefore, the Guidelines identify best practices
for psychologists who engage in preventive activities re-
lating to the interface between physical health and emo-
tional well-being.

The Guidelines also respond to policies and legislation
that aim to prevent and reduce problems such as chemical
addictions, depression, suicide, school bullying, social vi-
olence, and obesity (Institute of Medicine, 1994). The
Guidelines respond to social disparities, discrimination,
and bias against people based on (but not limited to) their
race, ethnicity, immigrant status, sexual orientation, age,
gender identity, socioeconomic status, religion, HIV se-
rostatus, physical and psychological health status, and gen-
der (APA, 2003, 2007; Kenny, Horne, Orpinas, & Reese,
2009). The Guidelines offer recommendations to psychol-
ogists as they respond to public policy and legislative
initiatives that promote positive health behaviors in the
name of prevention and health promotion (National Re-
search Council & Institute of Medicine, 2009). In addition,
the Guidelines endeavor to apply the science and practice
of psychology to address major social issues and real-world
problems through education, training, and public policy
positions (Anderson, 2011).

The Guidelines offer guidance to psychologists on
several levels, including supporting the value of prevention
as important work of psychologists and providing recom-
mendations that give greater visibility to prevention among
psychologists regardless of specialty area or work setting
(Snyder & Elliott, 2005).

Expiration
Given the evolving nature of prevention, the Guidelines are
scheduled to expire in the year 2020. After this date, users
are encouraged to contact the APA Practice Directorate to
determine if the document remains in effect. The year 2020
was selected because it coincides with the decennial
Healthy People publications, which set national health
goals for the United States every 10 years. In addition, it is
expected that the Patient Protection and Affordable Care
Act (2010) will be implemented fully by 2014, providing a
reasonable time frame for these Guidelines, given the
evolving nature of health care and psychology’s place
within the spectrum of health care services and research.

Guidelines
Guideline 1. Psychologists are encouraged to
select and implement preventive
interventions that are theory- and evidence-
based.

Rationale. Preventive interventions that demon-
strate sustained effectiveness can be considered as meeting
the highest standard for efficacy and maximum benefits to
the consumer (National Institute of Mental Health, 1998).
Consistent with foundational principles in psychology, the-
ory and research should be inseparably tied to prevention
practice. Research suggests that programs developed from
a sound theoretical framework are more effective than
programs that are not theoretically based (Weissberg,
Kumpfer, & Seligman, 2003). Also, preventive programs
that are based on theory and regularly evaluated are more
likely to consider risk and protective factors that operate
across multiple contexts (Black & Krishnakumar, 1998),
especially for groups who are historically marginalized
(e.g., women, people of color). Accountability to client
populations, funding agencies, and policymakers demands
that prevention practices be grounded in theory and re-
search (Vera & Reese, 2000).

Application. Psychologists are encouraged to
conduct preventive programs that have been rigorously
evaluated (Guterman, 2004; Weissberg, Kumpfer, & Selig-
man, 2003). While no single theoretical perspective is
suggested, psychologists are encouraged to select theoret-
ically based preventive approaches when considering their
prevention goals. The theoretical frameworks and interven-
tion strategies of positive psychology, positive youth de-
velopment, applied developmental science, risk and resil-
ience, health promotion, competence enhancement, and
wellness, among others, can be selected and integrated
when designing preventive interventions that will simulta-
neously prevent negative outcomes and enhance positive
outcomes (Weissberg, Kumpfer, & Seligman, 2003). It is
recommended that preventive programs be selected based
on a careful review of empirical evidence in order to
choose programs that are empirically supported for their
specific contexts and specified goals, in addition to identi-
fying how these relate to both multicultural issues and
concerns generated by social inequities. Therefore, it is
recommended that psychologists stay informed regarding
current outcome research in prevention science to help
ensure that the preventive programs they implement offer
the most promise for the identified goals and population.

Guideline 2. Psychologists are encouraged to
use socially and culturally relevant
preventive practices adapted to the specific
context in which they are implemented.

Rationale. Given the increasing diversity of the
U.S. population, it is crucial that preventive programs be
designed, selected, and implemented with consideration of
cultural relevance and cultural competence. Historically,
many preventive programs were developed by profession-
als working with urban and suburban middle-class com-

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287April 2014 ● American Psychologist

munities and reflect heterosexual European American val-
ues and methods; furthermore, many did not address the
unique issues faced by persons with disabilities. Preventive
programs that lack relevance to the lives of participants will
often fail (Lerner, 1995). Even when a preventive program
is effective in one setting, it may not be effective in another
setting with different populations (e.g., rural vs. urban
communities, individuals above and below the federal pov-
erty guidelines). Research suggests that programs per-
ceived as socially and culturally relevant by their constit-
uents have a greater likelihood of being sustained (Vera &
Reese, 2000). As Trickett et al. (2011) noted, “Culture is
not seen as something to which interventions are tailored;
rather, culture is a fundamental set of defining qualities of
community life out of which interventions flow” (p. 1412).

Because risk and protective factors are found within
individuals and in the multiple social contexts in which
individuals are situated, prevention programs that attend to
both individual and contextual factors are most advanta-
geous. Focusing only on individuals and the more proximal
context of the family may place undue responsibility and
blame on the individual and the individual’s milieu without
recognizing the roles played by social institutions and
culture in determining and sustaining positive human out-
comes (Kenny & Hage, 2009). Therefore, psychologists
strive to understand the cultural worldviews and commu-
nity contexts of individuals in order to strengthen preven-
tion interventions, especially interventions that have been
developed for one cultural group and implemented in an-
other (National Research Council & Institute of Medicine,
2009).

Application. Psychologists are encouraged to be
aware of and to articulate the evidence that supports their
selection of specific prevention programs for implementa-
tion in different cultural contexts (Reese & Vera, 2007).
Along this line, existing programs may need significant
adaptation, or new programs may need to be developed, to
meet social, cultural, community, and developmental
norms of program participants and to ensure access to all
members. Technological advances, such as the use of web-
based preventive interventions and social media to pro-
mote, deliver, and assess prevention interventions, can as-
sist with this process. Psychologists are encouraged to
recognize the diversity that exists within cultural groups as
cultural values may differ by race, ethnicity, social class,
family income, gender, gender identity, sexual orientation,
geographic region, education, ability, and acculturation
level (Kumpfer, Alvarado, Smith, & Bellamy, 2002). Psy-
chologists are encouraged to examine cultural assumptions
and biases of specific preventive programs and to consult
the APA’s (2003) “Guidelines on Multicultural Education,
Training, Research, Practice, and Organizational Change
for Psychologists” and its “Guidelines for Assessment of
and Intervention With Persons With Disabilities” (APA,
2012a) in integrating considerations of culture in the de-
sign, implementation, and evaluation of prevention inter-
ventions. It is important for psychologists to acquire and
demonstrate cultural competence across prevention activi-
ties and to strive to work sensitively with diverse popula-

tions. This typically means that the psychologist must
immerse him- or herself in the community and culture in
order to be a sensitive partner with the community.

Psychologists endeavor to include relevant stakehold-
ers in all aspects of prevention planning and implementa-
tion to ensure program fit with the local culture and to build
community investment in the program. In order to ensure
that preventive programs meet local norms, it is recom-
mended that psychologists engage in careful planning and
ongoing monitoring and evaluation of programs (Nation et
al., 2003). Dynamic trial designs have been proposed that
avoid problems associated with randomized clinical trials
and focus on whether significant information is lost as the
intervention proceeds (Jason & Glenwick, 2012), whether
there are unintended consequences (positive and negative)
that result from the intervention, and how to consider issues
of diversity when statistical power may be low (Rapkin &
Trickett, 2005).

Guideline 3. Psychologists are encouraged to
develop and implement interventions that
reduce risks and promote human strengths.

Rationale. Early prevention interventions fo-
cused on reducing risks or causes of psychological dys-
function (Conyne, 2004). However, psychological research
has identified personal and environmental protective fac-
tors that may also mitigate the probability of negative
outcomes in the face of risk and that contribute to optimal
health. Research indicates that prevention is most benefi-
cial when attempts to reduce risk are direct and are com-
bined with efforts to build strengths and protective factors
(Eccles & Appleton, 2002; Vera & Reese, 2000). Focusing
only on building competencies or only on preventing prob-
lems may not be as effective as addressing both competen-
cies and problems (Catalano, Berglund, et al., 2002).

Application. Psychologists are encouraged to
consider and ameliorate factors that contribute to risk and
also to recognize and promote factors that enhance human
strengths. Prevention programs can seek to reduce or elim-
inate factors, such as socioeconomic disparities, negative
peer influences, family dysfunction, and school failure, or
they can seek to increase social competencies and other
protective factors (National Research Council & Institute
of Medicine, 2009). Although psychologists may consider
only the benefits of either a risk-reduction or a strength-
promotion approach, an optimal approach is to address
both. Protective factors, such as socioemotional skills, in-
terpersonal connection, ethical decision making, graduat-
ing from high school, school-to-work transitions, civic
engagement, and proper nutrition, might be selected as foci
of interventions based upon their malleability and their
relevance to daily life (Eccles & Appleton, 2002; Nation et
al., 2003; Stone et al., 2003). For instance, a focus on
expanding the resilience that historically marginalized
groups have demonstrated despite obstacles might also
serve to enhance strengths in other arenas of life (Singh,
Hays, & Watson, 2011; Singh & McKleroy, 2011).

An emphasis on simultaneously reducing risks and
developing competencies is consistent with research on

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288 April 2014 ● American Psychologist

positive youth development, empowerment, advocacy, and
participatory community research. Positive youth develop-
ment posits that (a) protective factors reduce the likelihood
of maladaptive outcomes under conditions of risk and (b)
freedom from risk is not synonymous with preparation for
life (Catalano, Hawkins, Berglund, Pollard, & Arthur,
2002; Pittman, Irby, Tolman, Yohalem, & Ferber, 2001).
The APA Presidential Task Force on Prevention: Promot-
ing Strength, Resilience, and Health in Young People rec-
ommended that prevention encompass the goals of reduc-
ing health problems and promoting health and social
competence (Weissberg, Kumpfer, & Seligman, 2003).

Similarly, empowerment interventions focus on help-
ing individuals master and maintain control over life situ-
ations. Inherently, empowerment is concerned with com-
petencies and strengths (Zimmerman, 1995; Zimmerman,
Israel, Schulz, & Checkoway, 1992). Advocacy interven-
tions also have been implemented with populations such as
adjudicated youth (e.g., E. P. Smith, Wolf, Cantillon,
Thomas, & Davidson, 2004), and women experiencing
intimate partner violence (Allen, Bybee, & Sullivan, 2004).
Finally, participatory action research (PAR) interventions,
which focus on researcher–participant collaborations and,
thus, on utilizing strengths and competencies of the partic-
ipants, have been successfully implemented with diverse
groups of youth (e.g., Foster-Fishman, Law, Lichty, &
Aoun, 2010; Jason, Keys, Suarez-Balcazar, Taylor, & Da-
vis, 2003; L. Smith, Davis, & Bhowmik, 2010). It is
recommended that PAR be a genuine community–re-
searcher partnership (i.e., the development of shared goals,
shared methods, and shared sense of the value of the
project and the findings) to successfully implement the
methodology (Trickett, 2011).

Guideline 4. Psychologists are encouraged to
incorporate research and evaluation as
integral to prevention program development
and implementation, including consideration
of environmental contexts that impact
prevention.

Rationale. Prevention research encompasses
“theory and practice related to the prevention of social,
physical, and mental health problems, including etiology,
methodology, epidemiology, and intervention” (National
Research Council & Institute of Medicine, 2009, p. xxvii).
At its best, prevention research addresses multifaceted con-
texts (biological, psychological, and sociocultural levels)
and functions (preintervention epidemiology, preventive
interventions, and preventive service delivery systems; Na-
tional Institute of Mental Health, 1998). The contexts and
functions of prevention research can inform each other.
Problems and their prevention occur at interrelated biolog-
ical, psychological and sociocultural levels. Epidemiolog-
ical research can identify targets for preventive interven-
tions; evaluation of interventions can identify preferred
approaches that can be incorporated into service delivery
systems; the effectiveness and efficiency of service deliv-
ery systems can be assessed by examining their impact on
epidemiology. At all stages of the research process, the

dynamic interactions between biological, psychological,
and sociocultural environments are important to consider
(Albee, 1996). Research solely examining intrapersonal
factors that affect behaviors might ignore the context in
which the individuals’ behaviors occur and could result in
incomplete or misleading conclusions (National Institute of
Mental Health, 1998). It is important that prevention re-
search examine the etiology of maladaptive behaviors and
potential determinants, including biological, intrapersonal,
interpersonal, community, and societal risk and protective
factors. It is also recommended that evaluations of preven-
tion interventions address how adaptive behavioral changes
promoted by a specific program are valued within different
environmental contexts.

Application. Psychologists conducting research
on prevention are encouraged to take into account the
interface between biological, psychological, and sociocul-
tural variables and the best available evidence regarding
epidemiology, intervention, and service delivery. Re-
sources are available to identify evidence-based prevention
interventions for different demographics, topical areas, and
contexts. One such resource is the National Registry of
Evidence-Based Programs and Practices (http://www
.nrepp.samhsa.gov/Index.aspx), compiled by the U. S. De-
partment of Health and Human Services, Substance Abuse
and Mental Health Services Administration. Psychologists
are encouraged to consider the social ecology of the com-
munity in which they work (Bronfenbrenner, 1979) and to
collaborate with community stakeholders on research goals
and methods (Caplan & Caplan, 2000; Foster-Fishman,
Berkowitz, Lounsbury, Jacobson, & Allen, 2001; Sullivan
et al., 2001). Researchers are encouraged to assess the
differential impact of prevention programs on specific com-
munities. Prevention researchers may unknowingly design
and evaluate programs using criteria from their own cul-
tural perspectives and worldviews and may miss important
contextual factors that contribute to the success or failure of
prevention interventions within specific communities and
cultures (e.g., diverse social classes and socioeconomic
groups; Trickett, 1998; Turner, 2000). Community collab-
oration is important in the interpretation and application of
research findings and for the provision of oversight and
monitoring of community-based research. PAR is one ex-
ample of collaborative research that appreciates environ-
mental contexts and recognizes that knowledge is copro-
duced through collaborative actions with those who have
traditionally been left out of the research process and
whose lives are most affected by the research problem
(Prilleltensky & Nelson, 2002).

Guideline 5. Psychologists are encouraged to
consider ethical issues in prevention research
and practice.

Rationale. Psychologists are required to adhere to
ethical standards of the profession and to be mindful of its
highest ideals (APA, 2010). Prevention efforts may raise
unique ethical issues (Bond & Albee, 1990; Waldo, Kac-
zmarek, & Romano, 2004). Prevention is typically con-
ducted with numerous participants and has individual, sys-

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289April 2014 ● American Psychologist

www.nrepp.samhsa.gov/Index.aspx

www.nrepp.samhsa.gov/Index.aspx

temic, and societal implications. It is important to evaluate
possible negative impacts that preventive interventions
may have on individuals, the community, or the larger
society (Bloom, 1993; Caplan & Caplan, 1994). For exam-
ple, conducting preventive interventions that identify
higher risk within a historically stigmatized group could be
harmful to members of that group. Thus, it is important that
confidentiality be adhered to during the prevention inter-
vention process (Bloom, 1993). Additionally, targeted be-
havior may serve one or more purposes for the individual
and community; eliminating the behavior without attention
to its possible protective functions may lead to negative
consequences for a segment of the community.

Application. Psychologists are encouraged to be
knowledgeable regarding methods and designs in preven-
tion research and practice within their boundaries of com-
petence (APA, 2010, Ethical Standard 2.01). It is important
that preventive interventions and research include consid-
erations of the ethical implications of new or promoted
behaviors before, during, and after a prevention interven-
tion. Informed consent poses particular challenges with
regard to ensuring that individuals and multiple stakehold-
ers comprehend the implications of their participation.
Other ethical issues to consider include equitable selection,
confidentiality, cultural relevancy, socially and culturally
competent research and practice (APA, 2010, Ethical Stan-
dards 8.02 and 2.01b), and researcher bias (Schwartz &
Hage, 2009). It is important to evaluate the long-term
effects of preventive interventions (Brown & Liao, 1999),
especially as they relate to historically marginalized
groups.

Guideline 6. Psychologists are encouraged to
attend to contextual issues of social disparity
that may inform prevention practice and
research.

Rationale. Considerations of social disparities
can provide a context for prevention work in which the
causes and effects of oppression can be identified and
considered. Reducing social disparities is essential for pre-
venting the myriad of problems that they spawn (e.g., Vera,
Buhin, & Isacco, 2009). For example, children living in
disadvantaged neighborhoods are at risk for childhood be-
havioral difficulties, including conduct disorders, mental
health problems, academic failure, and teen pregnancy
(e.g., Goodnight et al., 2012; Harding, 2003; Leventhal &
Brooks-Gunn, 2000; Nikulina, Widom, & Czaja, 2011).
For adults, those living at or near poverty level have a
greater incidence of major depressive disorder than those
with higher incomes (e.g., Kessler et al., 2003). Further-
more, numerous health problems (e.g., diabetes, obesity,
coronary heart disease) have been associated with living in
poverty (e.g., Kittleson et al., 2006; Ludwig et al., 2011).
Consistent with these considerations, the importance of
creating contexts of fairness in order to improve the health
and wellness of those served by prevention programs has
been emphasized (Lawson, Noblett, & Rodwell, 2009; Pril-
leltensky, 2001, 2012; Tepper, 2001).

Application. Psychologists strive to be cognizant
of the social implications of the preventive services they
offer. For example, interventions that fail to consider those
structural inequalities and contextual factors (e.g., social
class, socioeconomic status) that influence behavior may
inadvertently suggest that the problem lies within a partic-
ular group instead of acknowledging the influence of being
marginalized in society (Walker, 2009). Prevention inter-
ventions may have maximum impact if societal inequalities
related to social class, economic status, discrimination, and
exploitation are considered (M. J. Perry & Albee, 1994).
Dissemination of prevention findings grounded in the so-
cial ecology of the community may aid in acknowledging
inequalities that may contribute to or exacerbate a partic-
ular behavior that is the target of intervention. For example,
lesbian, gay, bisexual, transgender, and queer young people
who are bullied in school may be experiencing not only
homophobia reactions from peers but also bullying based
on racial/ethnic, gender, and/or class identities (American
Psychological Association, 2012b; Singh & McKleroy,
2011).

Guideline 7. Psychologists are encouraged to
increase their awareness, knowledge, and
skills essential to prevention through
continuing education, training, supervision,
and consultation.

Rationale. The Guidelines and Principles for Ac-
creditation of Programs in Professional Psychology (APA,
2009) stress the importance of education and training that
cover the breadth of psychology. Research suggests that
prevention helps to reduce the need for remedial interven-
tions (Schwartz & Hage, 2009; Vera et al., 2009). There-
fore, remediation and prevention are best viewed as com-
plementary to one another, not in conflict. However,
despite psychology’s history with prevention practice and
research during the 20th century (Cowen, 1973; Elias,
1987), the education of psychologists continues to empha-
size crisis interventions and remedial approaches, giving
much less attention to prevention as a core component of
training and education (Matthews, 2003; O’Byrne, Bram-
mer, Davidson, & Poston, 2002; Snyder & Elliott, 2005).
Although some psychologists learn about the development
and implementation of prevention activities in graduate
school (e.g., community psychologists), most new preven-
tion interventionists do not have a high level of training in
the established content areas of prevention, and more-
established professionals report low levels of knowledge in
newer areas of prevention (e.g., gender and culture issues,
economic analysis of prevention; Eddy, Smith, Brown, &
Reid, 2005). This research suggests that much of the edu-
cation and training in prevention is learned through less
formal methods than graduate education. In psychology
graduate education, there is a need to expand opportunities
to learn about prevention by developing prevention-based
courses and/or infusing prevention-related content into ex-
isting courses (Conyne, Newmeyer, Kenny, Romano, &
Matthews, 2008; Matthews & Skowron, 2004).

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Application. The training and continuing educa-
tion of psychologists in awareness, knowledge, and skills
related to prevention provide psychologists with resources
to be proactive in reducing human suffering and in pro-
moting positive aspects of human functioning. Psycholo-
gists are encouraged to obtain education and training in
preventive approaches through various pathways, including
respecialization programs, postdoctoral fellowships, con-
tinuing education programs, self-study, conferences, pro-
fessional societies that focus on prevention, and combina-
tions of such alternatives. Other avenues include service
learning and experiential work in community settings less
typical for psychologists (DeLeon, Dubanoski, & Oliveira-
Berry, 2005). Predoctoral psychology graduate students
may also consider taking advantage of coursework, practi-
cum experiences, and predoctoral internships that have a
prevention focus. Psychology training programs can also
encourage enrollment in prevention courses in other disci-
plines, such as public health, thus encouraging training in
interdisciplinary perspectives important to prevention.
Those already in practice and unable to participate in
concentrated, formal training programs may be able to
utilize continuing education programs. Psychologists may
also gain supervised experience and consultation working
with psychologists, or other professionals, skilled in pre-
vention. Because public health has a strong focus on pre-
vention, increased training and collaboration with profes-
sionals in the field of public health are encouraged.
Through more formal education, psychology trainees and
psychologists may consider earning dual degrees in public
health (e.g., a master’s in public health) and psychology.
The collaborative training, which pairs psychologists’ un-
derstanding of human behavior and public health profes-
sionals’ knowledge of health and prevention at community
or population levels, may be particularly effective at cre-
ating change at the societal level. Literature relevant to
prevention is available through professional journals, in-
cluding a growing number of applied journals in, for ex-
ample, psychiatry, public health, and psychology. Preven-
tion research and applications are also disseminated
through professional organizations and their respective
conferences.

Scholars have noted several knowledge and skill do-
mains important to psychologists engaging in prevention
(Conyne, 1997; Hage et al., 2007; O’Neil & Britner, 2009).
The domains include (a) understanding distinctions be-
tween preventive and remedial approaches; (b) designing
and implementing educational programs; (c) assessing
community needs; (d) understanding systemic approaches
that incorporate cultural and contextual factors into preven-
tive interventions; (e) using group skills and approaches,
when appropriate, in program design and implementation;
(f) collaborating with interdisciplinary teams that include
professionals and community leaders; (g) grant-writing and
marketing skills to address sustainability of preventive
efforts; (h) promoting positive development across the life
span; (i) empowering individuals and communities to work
on their own behalf; (j) developing strength-based ap-
proaches that reduce risk and enhance resilience in indi-

viduals and communities; (k) influencing policy decisions
and their impact on preventive efforts; and (l) evaluating
preventive interventions. Each of these domains of knowl-
edge and skill in prevention ideally would include attend-
ing to the needs and concerns of historically marginalized
groups and would consider power differentials as they
relate to cultural differences and concerns of social inequal-
ities. In addition, training in newer technologies, such as
telepsychology and social media, is important as these
technologies are emerging methods for preventive efforts.

Guideline 8. Psychologists are encouraged to
engage in systemic and institutional change
interventions that strengthen the health of
individuals, families, and communities and
prevent psychological and physical distress
and disability.

Rationale. Applications of prevention through
systemic interventions are important across many domains.
Systemic preventive interventions include those that affect
families, schools, communities, and work environments.
Individuals may not be able to achieve maximum health or
full social participation if systemic barriers, such as clas-
sism, racism, sexism, and poverty, prevail. Preventive pro-
grams that focus only on changing individuals are likely to
be less effective than those that also address the contexts
that support or inhibit development and optimal health.
Systemic interventions can be delivered across the life
cycle, but the earlier prevention occurs, the greater the
likelihood of reducing risk and strengthening protective
factors (E. J. Smith, 2006). Systemic preventive programs
that focus on developing community norms that promote
healthy lifestyle behaviors are effective in reducing societal
problems (Orpinas, Horne, & the Multisite Violence Pre-
vention Project, 2004).

Application. Psychologists are encouraged to en-
gage in activities that produce positive systemic, institu-
tional, and organizational change. Psychologists can con-
tribute to systemic change that strengthens protective and
resiliency factors of individuals, families, schools, work-
places, faith communities, community centers, and health
care centers (Johnson & Millstein, 2003; Kumpfer & Al-
varado, 2003; Morsillo & Prilleltensky, 2007; Wandersman
& Florin, 2003). For example, organizational psychologists
can assist in the development of corporate policies to
reduce work stress and stress-related illnesses and to in-
crease worker satisfaction and productivity (Murphy, Hur-
rell, & Quick, 1992). Other examples include school-based
preventive programs that address the multiple needs of
students across the school and community. Such programs
have yielded positive results and enhanced students’ emo-
tional, social, and academic development (e.g., August,
Hektner, Egan, Realmuto, & Bloomquist, 2002; Greenberg
et al., 2003; Newman-Carlson & Horne, 2004). School-
based interventions that incorporate health promotion,
competence enhancement, and youth development as
frameworks for prevention can reduce youth risk behaviors
and enhance protective factors (e.g., C. L. Perry, 1999;
Weissberg & Greenberg, 1998). A recent meta-analysis of

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291April 2014 ● American Psychologist

after-school programs indicated that programs that foster
personal and social skills of youth provide the greatest
benefit (Durlak et al., 2010). School-based systemic inter-
ventions may also inform policies that address inequities
and discrimination among groups of students (Morsillo &
Prilleltensky, 2007).

Psychologists can influence the structure, role rela-
tionships, premises, rules, and assumptions governing sys-
tems to empower communities and to promote justice and
equity (Evan, Hanlin, & Prilleltensky, 2007). Psychologists
in health care settings can promote employee programs that
strengthen employee resiliency in order to inoculate em-
ployees against the physical and psychological demands of
the work setting (Freeman & Carson, 2006). Another area
of systemic application is advocating for healthy food
choices in cafeterias, lunchrooms, and vending machines to
promote healthy nutrition, which, when coupled with an
active lifestyle, can reduce obesity and resulting health
risks (Hawkes, 2007; Suarez-Balcazar et al., 2007).

Parent- and family-based interventions can help par-
ents and other caregivers learn effective child-rearing skills
to strengthen adult and child relationships, which, in turn,
reduce child and adolescent behavior problems and en-
hance learning (Thornton, Craft, Dahlberg, Lynch, & Baer,
2002). Applications of systemic prevention interventions at
later stages of life include community-based programs that
support older adults living in their homes. Elders with
sufficient physical and emotional capacity will benefit from
community preventive programs that involve them in com-
munity volunteer opportunities, public policymaking,
neighborhood networking, and social support groups (Kon-
nert et al., 1999).

Guideline 9. Psychologists are encouraged to
inform the deliberation of public policies that
promote health and well-being when
relevant prevention science findings are
available.

Rationale. Psychologists are well positioned to
educate and inform policymakers about the importance of
prevention to enhance health and well-being (Kiselica,
2004). For example, public policy– based prevention pro-
grams such as Project Head Start have been an integral part
of preventive initiatives that promote human functioning
and reduce negative health outcomes (Ripple & Zigler,
2003). Psychologists are encouraged to apply their exper-
tise by informing policymakers about the value of evi-
dence-based preventive initiatives and to communicate
their research findings clearly and concisely to policymak-
ers (Coates & Szekeres, 2004; Hage et al., 2007; Ripple &
Zigler, 2003).

Application. Psychologists are encouraged to be-
come informed about public policy debates in which pre-
vention research and programs may have relevant informa-
tion to contribute to the discourse. Psychologists strive to
enter such discussion and inform policymakers at local,
state, and national levels by using their expertise and schol-
arship in prevention science as appropriate. For example, at
the Surgeon General’s Conference on Children’s Mental

Health in 2000, psychologists provided recommendations
to help formulate a national policy on children’s mental
health (Levant, Tolan, & Dodgen, 2002). It is suggested
that psychologists become familiar with APA resources
that are relevant to health care policy and health promotion.
They are also encouraged to consider strengthening their
efforts by forming multidisciplinary partnerships that in-
clude government, legal, and policymaking experts, as well
as professionals from the health, social, and educational
sciences. For example, Jason (2012) described a 20-year
collaborative effort between psychologists and patient ad-
vocacy organizations to effect change in multiple areas
regarding the problem of chronic fatigue syndrome, includ-
ing epidemiological evidence, criteria for diagnosis, and
leadership at the Centers for Disease Control and Preven-
tion. As another example of collaboration, in 1965, Head
Start began as a White House initiative that included the
collaboration of psychologists, sociologists, and pediatri-
cians focused on the goal of reducing the deleterious effects
of poverty on young children (Styfco & Zigler, 2003).
Furthermore, it is recommended that graduate programs
teach students about the relationship between research and
its relevancy to informing policy (Ripple & Zigler, 2003).

Conclusion
The Prevention Guidelines encourage psychologists, in-
cluding those within the policymaking process, to strive to
engage in prevention practice, research, and education to
enhance human functioning. Prevention has numerous ben-
efits, including the potential to strengthen the integration of
science and practice in psychology (Biglan, Mrazek, Car-
nine, & Flay, 2003). Moreover, as discussed throughout the
Guidelines, the benefits of prevention have been demon-
strated through the reduction of illness and problem behav-
iors, the enhancement of human functioning, and the po-
tential to reduce health care costs (Durlak et al., 2010;
Institute of Medicine, 1994; Nation et al., 2003; National
Research Council & Institute of Medicine, 2009). An in-
creased focus on prevention has the potential to mobilize
psychologists to respond more effectively and sensitively
to conditions that place individuals, communities, and in-
stitutions at risk for various problems and to promote
strengths that contribute to human functioning.

The Guidelines provide a framework for best practices
in prevention and the promotion of health and well-being,
regardless of an individual psychologist’s specialty area,
employment setting, or professional interests. Infusing pre-
vention across the profession will help to orient psycholo-
gists to a broader application of psychological research and
practice, with the goal of more effectively and sensitively
responding to major societal needs for all individuals,
especially those with the fewest resources and groups his-
torically underserved by the profession.

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Appendix
Guidelines for Prevention in Psychology

Guideline 1. Psychologists are encouraged to select and implement preventive interven-
tions that are theory- and evidence-based.

Guideline 2. Psychologists are encouraged to use socially and culturally relevant preven-
tive practices adapted to the specific context in which they are implemented.

Guideline 3. Psychologists are encouraged to develop and implement interventions that
reduce risks and promote human strengths.

Guideline 4. Psychologists are encouraged to incorporate research and evaluation as
integral to prevention program development and implementation, including consideration
of environmental contexts that impact prevention.

Guideline 5. Psychologists are encouraged to consider ethical issues in prevention re-
search and practice.

Guideline 6. Psychologists are encouraged to attend to contextual issues of social disparity
that may inform prevention practice and research.

Guideline 7. Psychologists are encouraged to increase their awareness, knowledge, and
skills essential to prevention through continuing education, training, supervision, and
consultation.

Guideline 8. Psychologists are encouraged to engage in systemic and institutional change
interventions that strengthen the health of individuals, families, and communities and
prevent psychological and physical distress and disability.

Guideline 9. Psychologists are encouraged to inform the deliberation of public policies
that promote health and well-being when relevant prevention science findings are avail-
able.

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http://dx.doi.org/10.1001/archpsyc.65.12.1386

http://dx.doi.org/10.1001/archpsyc.65.12.1386

http://dx.doi.org/10.1037/0003-066X.58.6-7.441

http://dx.doi.org/10.1037/0003-066X.58.6-7.441

http://dx.doi.org/10.1037/0003-066X.58.6-7.425

www.who.int/whr/previous/en/index.html

www.who.int/whr/previous/en/index.html

http://dx.doi.org/10.1007/BF02506983

Guidelines for Prevention in Psychology
Purpose
Background
Definitions
Documentation of Need
Expiration
Guidelines
Guideline 1. Psychologists are encouraged to select and implement preventive interventions that …
Rationale
Application
Guideline 2. Psychologists are encouraged to use socially and culturally relevant preventive pra …
Rationale
Application
Guideline 3. Psychologists are encouraged to develop and implement interventions that reduce ris …
Rationale
Application
Guideline 4. Psychologists are encouraged to incorporate research and evaluation as integral to …
Rationale
Application
Guideline 5. Psychologists are encouraged to consider ethical issues in prevention research and …
Rationale
Application
Guideline 6. Psychologists are encouraged to attend to contextual issues of social disparity tha …
Rationale
Application
Guideline 7. Psychologists are encouraged to increase their awareness, knowledge, and skills ess …
Rationale
Application
Guideline 8. Psychologists are encouraged to engage in systemic and institutional change interve …
Rationale
Application
Guideline 9. Psychologists are encouraged to inform the deliberation of public policies that pro …
Rationale
Application

Conclusion
REFERENCES

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 Cho
1

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

Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.x

ª 2011 Blackwell Publishing Ltd

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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