Clinical Psychology

Not everyone whom we consider to be“disor-
dered”reports subjective distress. For example, clin-
icians sometimes encounter individuals who may
have little contact with reality yet profess inner tran-
quility. Nonetheless, these individuals are institution-
alized. Such examples remind us that subjective
reports must yield at times to other criteria. Another
problem concerns the amount of subjective distress
necessary to be considered abnormal. All of us
become aware of our own anxieties from time to
time, so the total absence of such feelings cannot
be the sole criterion of adjustment. How much anx-
iety is allowed, and for how long, before we acquire
a label? Many would assert that the very fact of being
alive and in an environment that can never wholly

satisfy us will inevitably bring anxieties. Thus, as in

the case of other criteria, using phenomenological

reports is subject to limitations. There is a certain

charm to the idea that if we want to know whether

a person is maladjusted, we should ask that person,

but there are obvious pitfalls in doing so.

Disability, Dysfunction, or Impairment

A third definition of abnormal behavior invokes the

concepts ofdisability, dysfunction, or impairment.For

behavior to be considered abnormal, it must create

some degree of social (interpersonal) or occupational

(or educational) problems for the individual. Dysfunc-

tion in these two spheres is often quite apparent to

illnesses like schizophrenia or dissociative disorder.

Stephen and Suryani (2000) note that this case might

be mistakenly diagnosed as one of mental illness by

diagnosticians who are not culturally informed. Gusti

A. successfully completed his university studies, his

own personal distress ceased once he realized that he

had these special abilities to heal others, and he is a

respected and well-functioning member of the com-

munity. Stephen and Suryani (2000) suggest that the

conversion to becoming a balian is like a religious

conversion rather than a sign of serious psychosis or

dissociation associated withDSM-IVdefined mental

illness.

So, does theDSM-IV-TR(APA, 2000) adequately

address the issue of culture and the diagnosis of

mental illness? Although most acknowledge that

the latest edition of the diagnostic manual does a

better job of attending to cultural issues than its

predecessors, Kleinman (1996) believes that the

diagnostic manual is too narrow in its perspective

and offers a few suggestions for future diagnostic

manuals:

■ Provide instruction on culturally sensitive diag-

nostic interviewing and culturally valid translation

and application ofDSM-based diagnostic tests and

research instruments.

■ Provide a Cultural Axis that assesses the person’s

cultural identity and degree of acculturation and

the likelihood for cultural obstacles.

■ Provide more information on cultural issues in

diagnosis like culturally relevant features as well

as a discussion of cultural influence on risk factors,

symptoms, and course of the disorder.

■ Finally, common cultural terms for distress and

culture-bound syndromes should be integrated

into the main text of the diagnostic manual (as

opposed to being placed in an appendix) so that

mental health professionals will be more aware of

the variations.

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DIAGNOSIS AND CLASSIFICATION OF PSYCHOLOGICAL PROBLEMS 137