Copyright 1994 by the American Psychological Association, Inc.

0021-843X/94/S3.00

Journal of Abnormal Psychology

1994, Vol. 103, No. 1,67-7!

Culture, Personality, and Psychopathology

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Roberto Lewis-Fernandez and Arthur Kleinman

Culture needs to be made more central to the understanding of personality and psychopathology.
New anthropological views describe cultural influences on personality and psychopathology by focusing on the effect of social change in local contexts on sociosomatic and sociopsychological processes. This view discloses the cultural biases built into dominant North American professional
models of diagnosis and contrasts with past uses of culture in cross-cultural research. Examples from
Chinese and Puerto Rican societies illustrate how indigenous interpersonal models of personality
and psychopathology that focus on social processes can augment the cross-cultural validity of clinical
formulations.

configuration of internal attributes that determine behavior

(Markus & Kitayama, 1991; Schweder, 1991). Radical egocentricity culminates in the idea that psychological normality and
abnormality are internal to the self, a notion that discounts the
social roots of psychiatric disease, the social course of mental
illness, and the interpersonal patterning of personality. By contrast, most of the world adheres to a more sociocentric ideology
(Schweder, 1991), nesting individual experience in networks of
social relationships that become the locus of self-worth, selffulfillment, self-control, and other attributes of the person (Markus & Kitayama, 1991; Triandis, 1989). Interpersonal obligations and loyalties loom larger in this ideology than individual
traits, and self-expression often requires an interpersonal idiom.
For example, in Chinese society, self-assertion is expected to
advance family interests. In this model, social networks influence personality development through reinforcement of culturally valued traits.
In a second culture-bound notion, dualism, events are held
to arise either in the brain or in the mind, with the former having greater reality. This leads to the division of psychopathology
into two camps: (a) organic disorders, which are experienced as
psychological distress, and (b) psychological problems, which
are somatized (reflected, for example, in separate categories for
organic mental disorders and somatoform disorders in the Diagnostic and Statistical Manual of Mental DisordersRevised
(3rd ed., rev. [DSM-IH-R]; American Psychiatric Association,
1987). Contrary to this professional model, the great majority
of the world's people, including many in North America, experience human suffering in an integrated, somatopsychological
mode: as simultaneous mind and body distress (Kleinman,
1988). The dualistic professional model systematically misinterprets the nondualistic cultural experience of patients as reflecting a lack of introspection or a so-called primitive cognitive
style and forces a differentiation between psychological and somatic experience where none exists.
A third culture-bound assumption behind professional mental health constructs is a view of culture as epiphenomenal. Culture is understood as a set of cognitive schema (beliefs), usually
held to be misinformed or superstitious, which are superimposed a posteriori on an invariant bedrock reality of biology
(Good, in press). This viewpoint leads to a discounting of the
disease categories, illness experiences, and healing practices of

In a world in which ethnic and cultural pluralism is daily

becoming more politically salient, it is striking that North
American professional constructs of personality and psychopathology are mostly culture bound, selectively reflecting the experiences of particular cohortsthose who are White, male,
Anglo-Germanic, Protestant, and formally educated and who
share a middle- and upper-middle-class cultural orientation.
Professional diagnostic criteria ignore the other populations
that constitute 80% of the world and are the most rapidly increasing segment (currently 25%) of United States society
(Gaines, 1992; Kleinman, 1988). This results in a largely ethnocentric psychology predicated on culturally specific ways of
viewing individuals and their personality development (Markus
& Kitayama, 1991), diagnostic categories of personality disorder that ignore the fundamental influence of social context and
cultural norms on human behavior (Nuckolls, 1992), and a psychiatric nosology that claims to be universal but does not take
seriously the great cross-cultural diversity of somatic and psychological symptoms (Mezzich et al., 1993).

Culture-Bound Ideologies of Psychology and Psychiatry

Three culture-bound assumptions bias professional concepts
of mental health and illness in North America: (a) the egocentricity of the self, (b) mind-body dualism, and (c) culture as
an arbitrary superimposition on a knowable biological reality.
Egocentricity is the commonsense understanding of the self as a
self-contained, autonomous entity, characterized by a unique

Roberto Lewis-Fernandez, Department of Social Medicine, Harvard

Medical School; Arthur Kleinman, Departments of Social Medicine
and Psychiatry, Harvard Medical School, and Department of Anthropology, Harvard University.
This article was written while Roberto Lewis-Fernandez was a National Institute of Mental Health Research Fellow in Clinically Relevant
Medical Anthropology (1991-1993; RER-2 5 T23 MH18006-07) at the
Department of Social Medicine, Harvard Medical School. Work on this
article was also supported by the MacArthur Foundation Research Network on Mind-Body Interactions and by the Nathan Cummings Foundation.
Correspondence concerning this article should be addressed to Roberto Lewis-Fernandez, who is now at P.O. Box 5131, Puerta de Tierra
Station, San Juan, Puerto Rico 00906.
67

68

ROBERTO LEWIS-FERNANDEZ AND ARTHUR KLEINMAN

people in other cultures, reducing them to the status of obstacles

in diagnosis, treatment compliance, and outcome.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Contributions of Anthropology, Cross-Cultural

Psychiatry, and Cultural Psychology
Until about 15 years ago, cross-cultural studies focused on
the shared belief systems of social groups (e.g., Mexican-Americans, the people of Bombay) and their culturally specific meanings about self, body, and health. Particular illnesses and therapies were held to be characteristic of entire populations (Fabrega & Manning, 1973; Harwood, 5981). More recently,
however, a new concept of culture has emerged that challenges
the idea of culture as a set of cognitive schemas (beliefs) distributed uniformly in a population. Instead, the new concept characterizes culture as value commitments and moral orientations
more akin to faith that are embodied in, and experienced by,
individuals as what is at stake in specific, local settings (local
moral worlds; Desjarlais, 1992; Good, in press; Kleinman &
Kleinman, 1991). Intracultural diversity is extensive, and recent cross-cultural health research has emphasized this diversity across lines of gender, class, age cohort, and political groups
(Das, in press; Kondo, 1990; Scott, 1990). The realities of health
and illness are shaped by ongoing interpersonal interactions: negotiations at the levels of perception, cognition, expressed emotion, and valuesall of which are involved in strategies for daily
coping that may be constrained, but certainly not determined,
by human psychophysiology (Good, 1992-1993).
In this anthropological perspective, interpersonal processes
bridge the social world and the body. Individual reality is the
lived experience of perceptions, meanings, affects, and actions
that come together (aggregate) at different levels and shape an
individual's insertion in the world as body, self, personality, and
member of a family and a social network (KJeinman &
Kleinman, in press). A collective reality, such as a political upheaval like the Cultural Revolution in China, may coalesce at
the level of the community in the nearly automatic action of a
mob, erupt in the family by disaggregating previously coordinated relationships, and be experienced as neurasthenia or major depression in an individual (KJeinman & KJeinman, 1991).
Conversely, the disaggregations of individual experience that we
call depression exist not just in the interior of the body-self but
equally at several social levels: in the demoralization caused by
political disenfranchisement, in an interpersonal language of
pain complaints, in the vexed communications between coworkers, in the undermining reactions of a spouse, as well as in
the loss of supporting social networks (Kleinman & KJeinman,
in press). From the perspective of the individual, the social
world and the body-self each influence the other (Ware &
KJeinman, 1992).
Personality and psychopathology take form in distinct local
worlds, characterized by behavioral environments consisting of
consensual orientations to self, objects, space, time, motivations, and moral norms that are culturally constituted, shared
to different degrees, and invoked differently in specific situations by members of the social group. Behavioral environments
vary greatly both across and within local worlds, leading to
multiple versions of self and personality that are constructed in
relation to not just other individuals but also whole communities, institutions, and even, in some settings, spirits and gods

(Hallowell, 1955). The attributes of self and personality are thus

more plural and fluid than generally described, dependent
largely on a changing behavioral environment that is fundamentally cultural (Kondo, 1990; Schweder, 1991). In this view, one
can speak of individual personality or of endogenous psychopathology in any one social setting only in a partial or heuristic
sense because the individualized perspective on personality reduces to internal manifestations what is fundamentally an interpersonally constructed experience of the self (Hermans,
Kempen, & van Loon, 1992).
From an interpersonal perspective, current Western theories
of personality, such as the Five-Factor Model (McCrae & John,
1992), appear more as highly abstracted expressions of individualistic personalities produced by modern rationalist behavioral environments than as a universal human pattern of personality dimensions. Despite the general cross-cultural applicability claimed by its exponents, the Five-Factor Model has been
empirically tested mostly on university-educated North American and Northern European samples (Angleitner, Ostendorf, &
John, 1990; Wiggins & Pincus, 1992). Early research performed in Asian societies was divided on the validity of the
model for these populations. Whereas Bond and coworkers
(Bond, 1979; Bond, Nakazato, & Shiraishi, 1975) found evidence to support it, Guthrie and Bennett (1971) did not. Bond
himself has recently criticized this early work on methodological grounds for obtaining the tested personality attributes solely
from North American terms, at times even without translation
into local languages (Yang & Bond, 1990). Studies that derive
personality questionnaires from indigenous concepts and languages show complex results that do not merely replicate Western findings (summarized in Yang & Bond, 1990). For example,
Yang and Bond used a mixture of native Chinese and translated
terms for personality attributes and found five to six personality
factors among Taiwanese university students, but these factors
deviated significantly from the components of the Five-Factor
Model. Yang and Bond cautioned other researchers against assuming that their results constituted the discovery of apparent
universals in human personality structure (p. 1094) because
cross-cultural research discloses diversity in personality as well
as psychopathology (Schweder, 1991).
In fact, experiences of self and personality are much more
diverse than previously assumed by either purely egocentric or
sociocentric philosophies. Among many Japanese and Chinese,
the self is presented differently depending on social context. For
example, self-assertion independent of group influence is considered appropriate to some settings but not others (Kondo,
1990; Rosenberger, 1992; Triandis, Bontempo, Villareal, Asai,
& Lucca, 1988). A society, then, consists of a unique mix of
egocentric and sociocentric traits (Markus & Kitayama, 1991).
The Chinese, for example, have been characterized as both sociocentric members of family groups and rugged individualists
(Lin, 1988).
In summary, a cultural theory of personality and psychopathology neither attempts to do away with the notions of the selfaware person or of individual agency nor denies the influence
of enduring biological propensities such as temperament and
coping style on human personality (Kagan & Snidman, 1991).
It does assert, however, that the local cultural world precedes the
appearance of the individual and fundamentally patterns his or
her developing biological and psychological processes. Interper-

CULTURE, PERSONALITY, AND PSYCHOPATHOLOGY

sonal experiences are contested and negotiated by real people

who differ, often greatly so, in their trajectories and engagements in life. Yet their mind-body states and notions of personality are profoundly shaped by collective cultural paradigms.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

A Contextualized Theory of Personality and

Psychopathology
Findings from our research among Chinese in Taiwan and
the People's Republic of China (Arthur Kleinman) and among
Puerto Ricans in Boston and Puerto Rico (Roberto Lewis-Fernandez) illustrate the interpersonal approach to personality theory and psychopathology. Chinese conceptions of self and personality, for example, are intimately related to the culturally
ascribed characteristics of the family, which is seen as an immortal structure in which the individual constitutes only a temporary, subordinated part. Within the family, the person's character is modulated by birth order and gender and is organized
by obligation, loyalty, and social control; outside the family, personality characteristics are formed by social attributions of position, prestige, and power, which are transmitted across generations in enduring social networks (Kleinman & Kleinman,
1992). Degrees of intimacy are transacted according to family
and social network membership, giving rise to significant variability in the form in which the self is presented to others and
thus in the pattern of personality attributes that are interpersonally reinforced (Kleinman & Kleinman, 1991; Lin, 1988).
Another cultural feature shaping the interpersonal construction of self and personality in Chinese communities is the premium placed on the subtle expression of affect (Tu, 1992). The
Wei Dynasty text Jen wu chih (On Human Personality) by Liu
Shao (3rd century/1937) presents a political and transactional
view of the self based on affective control (see also Myers, 1991,
for a comparison with Australian Pintupi aborigines). Mastery
of social relations, conceived as the goal of personality development, is achieved by the studied balancing of emotion, position
in the social field, and the specifics of the situation. Thus, state
dimensions of personality are culturally regarded as more important than trait dimensions; emphasis is placed on blandness
to foster flexible negotiation of changing situations (Kleinman
& Kleinman, 1991).
Because of this favored cultural pattern of affective subtlety,
self-mutability, and contextual idioms of self-expression, which
differs across class and age cohorts, the management of emotions becomes a major currency of relationships and a hallmark
of health in Chinese communities. As renqing (favor based on
human feelings and moral sensibility), emotion is a resource
that can be exchanged, owed, or given as a gift along networks
of social connections (quanxi) that bind participants in rules of
reciprocity (bao; Hwang, 1987). The appropriate exchange of
favor energizes the social net with qi (vital force), which results
in healthy individual minds, bodies, and communities. Favor
connects with face (mianzi, lianzi), an embodiment of social
power that represents one's moral capital and one's prestige in
the interpersonal field. To lose face is to lose one's ability to
engage in reciprocal affective relationships guided by moral
norms involving renqing; it is to be demoralized, bereft of qi,
and quite literally faceless, unable to look directly at others. The
loss of face can lead to illness, such as neurasthenia, or to problems in personality development. The unmediated expression

69

of strong emotion is also thought to lead to illness (Kleinman &

Kleinman, 1992). Thus, personality and affect are defined and
experienced as sociomoral processes.
Personality problems and psychopathology arise and are expressed as resentment toward family, as loss of face and favor,
and as powerlessness of self and network (Yu, 1991). Although
there is substantial intracultural diversity, these typical Chinese
patterns lead, in turn, to greatly different patterns of suicide
(Li & Baku, 1991); distinctive somatopsychological modes of
experiencing and expressing clinical depression (Kleinman,
1986); cultural syndromes, including possession by ancestors
and ghosts and obsession with semen loss; and predictable
differences in the course of schizophrenia (Xiong & Phillips,
1993). There are also distinctive patterns of help-seeking, treatments, and responses to clinical services (Kleinman, 1980).
Puerto Rican culture is also plural. A key element of the behavioral environment of traditional inhabitants of the mountainous interior of the island (jibaro culture) (Alonso, 1849;
Melendez-Munoz, 1963; Wolf, 1952) is the idea that everybody
in the community is linked in a mysterious but omnipresent
and powerful way. The negative impact of others can be felt despite the absence of any concrete action on their part through
the richly elaborated mechanisms of envidia (envy, collective
resentment of perceived advantage), mal de ojo (evil eye, a
sometimes unwilled projection of harm), and brujeria (witchcraft, a usually purposeful attack). In addition, knowledge of
community members' lives can come from extrasensory
sources, thus exceeding their own disclosures. These premonitions frequently appear in dreams and intuitions but occasionally can be received as visions and voices thought to be mediated
by spiritual agents and sought in organized ritual practices,
such as espiritismo (Nunez-Molina, 1987). This experience of
the behavioral environment as a fully interactive and nearly omniscient totality leads to a particular jibaro construction of the
self centered around the careful management of personal disclosure, effectively muting distinguishing features of personality
in regular social contact and channelling individualistic expression and the experience of personality difference into a small
number of protected relationships. Intimacy is based on relationships of confianza (confidence, trust) that are carefully
managed, as this special quality of openness is considered easily
lost or betrayed. Confianza can be cemented through an incorporation of the other into the status of family member via the
fictive kinship of compadrazgo (literally, co-fathership) arranged by mutual sponsorship of children's baptisms (Alonso,
1849; Melendez-Munoz, 1963).
The networks of confianza serve as dissipators of certain emotions that are culturally understood to be potentially disruptive
of social life because they lay claim to a significant amount of
relational capital, such as anger or jealousy. Self-control over
these emotions marks the presence of a fully socialized mature
actor and constitutes a principal component of jibaro self-perception and a source of self-esteem, encapsulated in the proud
comments: "X> me se controlar" ("I know how to control myself") and " Yo pongo de mi parte" ("I do my part" or "I give my
share of effort"). The most significant intracultural variations
in these ideas are determined by gender roles. Women are socially expected to exert greater self-control than men, who are
permitted a broader expression of emotions and desires, including anger, aggressiveness, and sexual attraction (Koss-Chioino,

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70

ROBERTO LEWIS-FERNANDEZ AND ARTHUR KLEINMAN

1992; Munoz- Vazquez, Macksoud-Lopez, & Cantera-Espinosa,

1992; Wolf, 1952). Because relationships ofconfianza serve as
channels for strong emotion, women are thus considered in
greater need of them than men. This goes along with notions
of greater interpersonal sensitivity among women, predisposing
them to the strong experience of socially determined emotion.
The lack of relational outlets, or the sheer force of certain undomesticated affects such as acute bereavement, is thought to
lead women (and men, to a lesser extent) to somatopsychological illness. This experience takes shape primarily as distressing
somatic symptoms and undifferentiated nervousness rather
than as intense emotionality, given the cultural stigmatization
of the articulated expression of negative emotions (Koss-Chioino, 1992). Emotional pathology is mediated, in this cultural
view, through damage to the conduits of emotions, the anatomical nerves. The result is the eloquent but nondisclosing somatized afflictions of nervios (nerves) and ataques de nervios (attacks of nerves), characterized by a propensity toward
trembling, insomnia, low energy, worry, anguish, and bouts of
paroxysmic screaming, aggressivity, hyperventilation, bodily
heat, and dissociation after stressors of diverse severity (Guarnaccia, De la Cancela, & Carrillo, 1989; Guarnaccia, Good, &
Kleinman, 1990; Lewis-Fernandez, 1992a).
The paroxysmic ataque temporarily breaks down the culturally authorized construct of self as the agent of behavior, in that
the person is not considered the source of the attack. Instead, it
is thought to stem directly from the precipitating emotion (e.g.,
grief). This etiology is reflected in the common phrase "eso no
estaba en mi" ("that [the outburst] was not part of me" [literally, "in me"]), richly suggesting that the socialized me would
never have behaved so badly on purpose. The ataque ripples
over the surface of the self but cannot be attributed directly to
it. This disavowal of the self from the origin of behavior is frequently experienced as dissociation at the height of the ataque,
when consciousness, memory, and somatomotor control can
become discontinuous (Lewis-Fernandez, 1992b, in press). The
ataque can also lead to a restructuring of the current pattern of
family relations, which often is the very source of the precipitating stressor (Guarnaccia et al., 1989; Koss-Chioino, 1992).
To be understood, these behaviors must be cautiously interpreted for specific contexts that vary, change, and exert different
effects; otherwise, one ends up with cultural stereotypes rather
than culturally informed clinical formulations.

Conclusion
The interpersonal study of mental health categories in local
worlds based on recent anthropological concepts of culture is
able to capture the cross-cultural and intracultural complexity
of human personality development and psychopathology. Current professional theories, in contrast, are wedded to individualistic assumptions that represent largely unexamined North
American and Western European cultural common sense that
deemphasizes the complex influence of social categories and relationships on experience. Clinicians and researchers trained to
contextualize behavior and experience as a function of radically
different environments would be less prone to category fallacies
(Kleinman, 1977), that is, the imposition of one culture's categories onto another culture, for which they lack validity. We
would be less likely to explain, for example, the adaptational

strategies of impoverished inner-city minority youth to highly

dangerous predatory environments as antisocial personality
disorder, a condition that has evolved out of a different class,
ethnic, and historical context. We would take relevant cultural
and gender norms into account before raising the question of
pathological dependency or lack of individuation among Chinese or Latinos. We would consider the relevant behavioral environmentwhich includes a normative discourse on spirits
and godsbefore speaking of a hysterical predisposition to possession trance among the people of India. We would also not
seek to pathologize each instance of somatization or to talk
about others' culture-bound syndromes as esoteric and exotic
without considering the effects of mind-body dualism on our
own professional but still culture-bound categories, such as anorexia nervosa and perhaps borderline personality disorder.
And we might very well come across local indigenous categories, such as face and favor, that can be used to reformulate our
leading models of personality formation and their relationship
to psychopathology.

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Received April 5, 1993

Revision received August 25, 1993
Accepted August 25, 1993