International Perspectives in Psychology 2021 by Hogrefe

Volume 10 / Number 1 / 2021 Editor-in-Chief Stuart Carr Associate Editor Ines Meyer

International Perspectives in Psychology Research, Practice, Consultation Official Journal of Division 52 (International Psychology) of the American Psychological Association

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International Perspectives in Psychology Research, Practice, Consultation

Volume 10/Number 1 /2021 Official Journal of Division 52 (International Psychology) of the American Psychological Association

Editor-in-Chief

Stuart Carr, Industrial and Organisational Psychology Programme, School of Psychology, Massey University, Auckland, New Zealand (Tel. +64 9 414 0800 43108, E-mail S.C.Carr@massey.ac.nz)

Associate Editor

Ines Meyer, Section for Organisational Psychology, School of Management Studies, University of Cape Town, Republic of South Africa (Tel. +27 21 650 3829, E-mail Ines.Meyer@uct.ac.za)

Editorial Board

Glenn Adams, USA Alfred Adegoke, Nigeria Ramadan Ahmed, Kuwait Rubén Ardila, Colombia Brien Ashdown, USA Jean Becker, Canada Jacob Bentley, USA Lynette Bikos, USA Jill Bloom, USA Merry Bullock, USA Xinyin Chen, USA Patricio Cumsille, Chile Francois de Kock, Republic of South Africa Neil Drew, Australia Patricia Dudgeon, Australia Shahla Eltayeb, Sudan Gillian Finchilescu, Republic of South Africa Yvette Flores, USA Márta Fülöp, Hungary Judith Gibbons, USA Danilo Silva Guimãres, Brazil Jarrod Haar, New Zealand John Hattie, Australia Darrin J. Hodgetts, New Zealand Yoshito Kawabata, Guam Brigitte Khoury, Lebanon Andreas Maercker, Switzerland Drew Mallory, Thailand Anthony Marsella, USA Vicente Martinez-Tur, Spain Gustavo Martineli Massola, Brazil

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International Perspectives in Psychology (2021), 10(1)

Ishbel McWha-Hermann, UK Elias Mpofu, Australia Kostas Mylonas, Greece Linda Waimarie Nikora, New Zealand Johanna Eva Nilsson, USA Kathryn Northsworthy, USA Katelyn Poelker, USA Ian P. Purcell, Australia Ashley Randall, USA Anu Realo, Estonia Marı́a Cristina Richaud de Minzi, Argentina Helen Ross, Australia David Sam, Norway Raymond Saner, Switzerland Mahima Saxena, USA Rosalind Searle, UK Robert Serpell, Zambia Nancy M. Sidun, USA Michael Stevens, USA Sunita Stewart, USA Aurora Szentágotai, Romania Junko Tanaka-Matsumi, Japan Catherine Tang, Singapore Jyotsna Vaid, USA Karen van Oudenhoven-van der Zee, The Netherlands Li Wang, P. R. China Colleen Ward, New Zealand Danny Wedding, USA Lichia Yiu, Switzerland

Contents Editorial

New Frontiers for International Perspectives in Psychology: Building Forward Better Stuart C. Carr and Ines Meyer

Articles

Culture, Subjectivity, and Music in Puerto Rico: Bomba, Plena, and the Ousting of a Governor Teófilo Espada-Brignoni and Frances Ruiz-Alfaro

Development, Construct Validity, and Measurement Invariance of the Parasocial Relationship With Political Figures (PSR-P) Scale Moh Abdul Hakim and James H. Liu

Pakistani Immigrants’ Nuanced Beliefs About Shame and Its Regulation Fanie Collardeau, Muhammad Usama Bin Aftab, Tahira Jibeen, and Erica Woodin

Massacre, Earthquake, Flood: Translational Science Evidence That the Use of Micronutrients Postdisaster Reduces the Risk of Post-Traumatic Stress in Survivors of Disasters Julia J. Rucklidge, M. Usman Afzali, Bonnie J. Kaplan, Oindrila Bhattacharya, F. Meredith Blampied, Roger T. Mulder, and Neville M. Blampied

Syrian Refugee Access to and Quality of Healthcare in Turkey: A Call to Streamline and Simplify the Process En Chi Chen

Policy Brief

International Perspectives in Psychology (2021), 10(1)

Editorial New Frontiers for International Perspectives in Psychology Building Forward Better Stuart C. Carr1 and Ines Meyer2 School of Psychology, Massey University, Aukland, New Zealand

School of Management Studies, University of Cape Town, Rondebusch, South Africa

2021 is not only the start of a new year, but it is also the start of a new publisher for International Perspectives in Psychology: Research, Practice, Consultation (IPP). We are delighted to be publishing with, and to be published by, Hogrefe. In our last editorial of 2020, we focused on building back better (Carr & Meyer, 2020). In this issue of IPP, by contrast, we focus on building forward better, through our new publishing partnership with Hogrefe. Already, for example, Hogrefe has just announced a very exciting and innovative development for the road ahead – researchers from most of the relevant scientific and research institutions in Germany, a total of 113 institutions, will be able to publish their articles in Hogrefe journals open access from 2021 onwards, at no additional cost (Hogrefe, 2020). We therefore call on contributors across Germany, and more importantly your international colleagues and research partners, to consider submitting your international perspectives in psychology to IPP! Speaking of international ethos, diversity, and inclusion, this issue is incredibly diverse, not only in topics but also in the places from which, and in which, they are grounded. They span a range of methods and approaches. They speak to a variety of interconnected goals and values espoused in the journal’s ambit and ethos. They include a perspective from the creative arts on political change in Puerto Rico (Espada-Brignoni & Alfaro, 2021) and, in response to an earlier call for a special issue on populism, para-social relationships with populist leaders across (and within) Indonesia, the United States, and in New Zealand (Hakim & Liu, 2021). We have further articles on the psychology of shame, building more inclusive human services, among Pakistani immigrants in Canada (Collardeau et al., 2021); and on the potential role of micronutrients in helping to combat traumatic stress following events like the Christchurch shootings and other natural and manmade

disasters (Rucklidge et al, 2021). Finally, we have a Policy Brief on how to streamline access to host country humanitarian services like healthcare for refugees from Syria in Turkey (Chen, 2021). Empowerment and change, mobility and recovery from disasters, and building forward into more inclusive human services – these are all hallmark themes in IPP and our home, Division 52 – International Psychology (https://www.apa.org/about/division/div52). As we turn now to face forwards into 2021, we are very excited and humbled to be working together with Hogrefe to build forward better. Keep your eyes open for our forthcoming special issues across a range of topics, from decent work and global changes in the world of work, on women during COVID-19, and psychology during the COVID-19 pandemic (https://www.hogrefe.com/us/ journal/international-perspectives-in-psychology-researchpractice-consultation). Above all, please do consider sending us your ideas for future special issues, and formats, and your research articles and policy briefs. Feel free to contact us directly on S.C.Carr@Massey.ac.nz and/or I.Meyer@uct.ac.za. We warmly welcome your innovative ideas and feedback on the contents of the journal, present and future, and look forward to building forward better with all of us during the new year ahead.

References Carr, S. C., & Meyer, I. (2020). Building back better with international perspectives in psychology. International Perspectives in Psychology: Research, Practice, Consultation, 9(4), 191–192. https://doi.org/10.1037/ipp0000148 Chen, E. C. (2021). Syrian refugee access to and quality of healthcare in Turkey: A call to streamline and simplify the process. International Perspectives in Psychology: Research, Practice, Consultation, 10(1), 55–57. https://doi.org/10.1027/2157-3891/a000005

International Perspectives in Psychology (2021), 10(1), 1–2 https://doi.org/10.1027/2157-3891/a000006

Collardeau, F., Bin Aftab, M. U., Jibeen, T., & Woodin, E. (2021). Pakistani immigrants’ nuanced beliefs about shame and its regulation. International Perspectives in Psychology: Research, Practice, Consultation, 10(1), 25–38. https://doi.org/10.1027/2157-3891/a000004 Espada-Brignoni, T., & Alfaro, F. R. (2021). Culture, subjectivity, and music in Puerto Rico: Bomba, plena, and the ousting of a governor. International Perspectives in Psychology: Research, Practice, Consultation, 10(1), 3–12. https://doi.org/10.1027/2157-3891/a000001 Hogrefe. (2020). Hogrefe and SUB Göttingen pave the way to Open Access [Press release]. Hakim, M., & Liu, J. H. (2021). Development, construct validity, and measurement invariance of the para-social relationship with political figures (PSR-P) scale. International Perspectives in Psychology: Research, Practice, Consultation, 10(1), 13–24. https://doi.org/10.1027/2157-3891/a000002 Rucklidge, J. J., Afzali, M. U., Kaplan, B. J., Bhattacharya, O., Blampied, F. M., Mulder, R. T., & Blampied, N. M. (2021).

International Perspectives in Psychology (2021), 10(1), 1–2

Editorial

Massacre, earthquake, flood: Translational science evidence that the use of micro-nutrients post-disaster reduces the risk of post-traumatic stress in survivors of disasters. International Perspectives in Psychology: Research, Practice, Consultation, 10(1), 39–54. https://doi.org/10.1027/2157-3891/ a000003

Published online February 17, 2021 Stuart Carr Industrial and Organisational Psychology Programme School of Psychology Massey University Auckland New Zealand s.c.carr@massey.ac.nz

Article

Culture, Subjectivity, and Music in Puerto Rico Bomba, Plena, and the Ousting of a Governor Teófilo Espada-Brignoni1 and Frances Ruiz-Alfaro2 Division of Social Sciences, Antioch College, Yellow Springs, OH, USA

Department of Psychology, University of Puerto Rico, Rı́o Piedras Campus San Juan, Puerto Rico

Abstract. Understanding human phenomena requires an in-depth analysis of the interconnectedness that arises from a particular culture and its history. Subjectivity as well as a collective subjectivity emerges from human productions such as language and art in a specific time and place. In this article, we explore the role of African-based popular music genres such as bomba and plena as ways of negotiating narratives about Puerto Rican society. Popular music encompasses diverse meanings. Puerto Rican folk music’s subjectivity provides narratives that distance Puerto Ricans from an individualistic cosmovision, allowing us to understand the social and political dimensions of this complex Caribbean culture. The events of the summer of 2019, which culminated in the ousting of governor Ricardo Rosselló from his position, illustrate how music can foster social change. Keywords: music, subjectivity, Puerto Rico, culture Impact and Implications. This paper reflects on the ways in which popular music gives meaning to both the individual and social dimensions of people in Puerto Rican culture. When we study the cultural and historical conditions that make up subjectivity, psychologists can better understand how underrepresented groups experience their realities.

During the past couple of decades, psychologists have increasingly recognized the importance of building theories and committing to practices that understand human experience as situated and mediated by singular cultural and historical forces (Denzin, 2010; Kim et al., 2006). Scholars working in fields such as social (Gergen, 1973; Nisbett, 2004), community (Lomotey-Nakon, 2018), cultural (Nisbett & Cohen, 1996), cognitive (Bruner, 1990; Varela et al., 2016), and developmental psychology (Nelson, 2007; Riegel, 1976) have turned to, been inspired by, or developed approaches encompassed in umbrella terms such as critical theory, postcolonial theory, discursive psychology, narrative psychology, sociocultural approaches, embodied cognition, and liberation psychology, among others. These critical theorizations and practices encourage researchers to analyze individuals as active members of a culture (Bruner, 1990; Kim et al., 2006). The qualitative, quantitative, and historical studies generated from the fields and perspectives mentioned above highlight the importance of understanding human beings as the outcome of multiple processes, some of which are embedded in human culture. One of the human activities that play a fundamental role in the socialization of individuals as members of cultures and communities as

well as their possible relations to other groups is music. As Mattern (1998) argued, “The communities that musicians have helped to form and sustain provide the social basis for political action that would be difficult or impossible among individuals who are not tied together in this way” (p. 5). Similarly, communities might change their expectations about the political commitment of musicians when the life of the collective is disturbed in unprecedented ways. In this article, we review some aspects of Puerto Rican culture, history, and music and how they supported the events of Verano del 19 (the summer of 2019). We are particularly interested in the role of African-based popular music in fostering a sense of community among Puerto Ricans constructing confrontational positions toward the governor. The massive popular demonstrations of the summer of 2019 have many complex causes embedded in the sociopolitical history of the island. However, this social movement was sparked by the publication of a leaked chat where the former governor of Puerto Rico, Ricardo Rosselló, and members of his administration made derogatory comments against Puerto Ricans, women, the LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer) community, and the people who died during and in the aftermath of Hurricane Marı́a. While Puerto Ricans had previously organized rallies,

International Perspectives in Psychology (2021), 10(1), 3–12 https://doi.org/10.1027/2157-3891/a000001

T. Espada-Brignoni & F. Ruiz-Alfaro, Culture, Subjectivity, and Music in Puerto Rico

general strikes, and acts of civil disobedience to demand change, the magnitude of the demonstrations of the summer of 2019 was unprecedented and culminated in a new pivotal moment in the history of the archipelago: the ousting of governor Ricardo Rosselló from his position. We hope this review supports and inspires quantitative and qualitative studies about Puerto Rican subjectivity in the fields of social, cultural, and clinical psychology. In the following sections, we borrow from several psychological fields, political science, anthropology, and related disciplines to define the series of concepts we have been using in our analysis of music as a sociopsychological phenomenon embedded in cultural practices and history. We then discuss some general features of Puerto Rico and relevant characteristics of the people of the archipelago. Then, we review social psychological theory and the history of Puerto Rico as a way of understanding Puerto Rican subjectivity. We use the ideas developed in these sections to analyze the protests of the summer of 2019 and the role music played.

Culture, Subjectivity, and Puerto Rican Music Concepts such as culture, subjectivity, and music are elusive. The definitions we use in this article reflect our theoretical perspective and research goals. They are not meant as prescriptive or universal definitions. On the contrary, the definitions discussed throughout this paper open the possibilities for the multiplicity of meanings that arise in the study of social and psychological processes. Kim and Park (2006) define culture as “an emergent property of individuals interacting with, managing, and changing their environment” (p. 34). These interactions are also “shared habits of thought and action and our repertoires of choices” (Turino, 2008, p. 17). Bruner (1990) adds that cultures have “interpretive procedures for adjudicating the different construals of reality that are inevitable in any diverse society” (p. 95). Music is an excellent repository of narratives about the world and a site negotiating interpretations of reality as well as a repository of the ideas and habits shared by a community. In this article, we define subjectivity as the collection of somewhat interconnected discourses (Lemke, 2019; May, 1993), narratives (Bruner, 1990), and bonds (Pichon-Rivière, 1985) individuals acquire throughout their interactions with members of their culture, institutions, and themselves. This occurs through socialization and self-regulation in the process of making meaning about the world. Furthermore, the contents of International Perspectives in Psychology (2021), 10(1), 3–12

one’s culture are not acquired passively. During socialization, individuals (the child and the caregiver, for example) give meaning to an event according to their position and interests (Nelson, 2007). While some of these terms used above in our definition of subjectivity are contested and there are some overlaps among them, they can also be used to refer to specific levels or elements of how members of a culture experience their world. The notion of discourse has been used by some psychologists, drawing on the work of Foucault, to study the statements about the world that are held as truth in a society and are embedded in multiple social practices (Hook, 2007; Parker, 1996). Bruner (1990) uses the notion of narrative to understand how individuals structure their experience. Among other things, narratives forge the “links between the exceptional and the ordinary” (p. 47). While the notion of discourse refers to higher-level ideas at institutional levels (such as the nature of living beings), we use Bruner’s (1990) notion of narrative as a mid- and lowlevel aspect of subjectivity that relates more specifically to how individuals negotiate meanings within themselves and with others (such as what members of a culture or group would find classify as an ordinary state of affairs or unacceptable). Expanding on attachment theory, PichonRivière (1985) defines bonds as a continuous and bidirectional affective negotiation between the individuals and the world as mediated by the groups individuals belong to. From this perspective, the bonds we forge with other subjects, objects, and institutions carry unconscious meanings that are embedded within a collective subjectivity referred to in the idea of cosmovision. In his last works, Foucault used the notion of subjectivation to study subjectivity without reducing it to traditional psychology and psychoanalysis (May, 1993). Subjectivation then refers to the ways in which individuals in a particular historical moment make sense of themselves and fashion possible ways of conducting their lives (Foucault, 1990). Foucault’s concept deals specifically with the tensions between the idea of an “autonomous subjectivity” free from social control and “heteronomous subjection” (Oberprantacher & Siclodi, 2016, p. 1). We use the notion of subjectivation to qualify one aspect of subjectivity in a cultural context—that is, the self-organized set of shared notions about the self and its relations to the world, or more specifically, those ideas and practices that go beyond the interdictions and prescriptions of dominant groups or society at large. Later in the article, we combine the concept of subjectivation with some ideas from crowd psychology as a way of analyzing and asking questions about the relationship between culture, subjectivity, and collective resistance. The concept of music is as elusive as that of subjectivity, if not more so. In this article, we are interested in music as © 2021 Hogrefe Publishing

T. Espada-Brignoni & F. Ruiz-Alfaro, Culture, Subjectivity, and Music in Puerto Rico

a sociopsychological phenomenon. According to Turino (2008), music “and other public expressive cultural practices are a primary way that people articulate the collective identities that are fundamental to forming and sustaining social groups” (p. 2). This definition is useful for our purposes since African-based musical genres, such as bomba and plena, are used in Puerto Rico and by the Puerto Rican diaspora as a way of asserting their identity (Flores, 2000). Furthermore, as Mattern (1998) argued, “music is a communicative arena in which various political actors can pursue multiple, often contradictory, agendas in which there are no guarantees of a positive democratic outcome” (p. 146). Both functions of sustaining social groups and pursuing political goals (which are not mutually exclusive) promote the affective bonds individuals have with others. These bonds carry collective subjectivity through the intergenerational transmission of meanings. Music can convey meaning with or without words while mediating how we experience the world. As Mattern (1998) analyzes in Acting in concert, lyrics can define the boundaries between groups and their relations with others. Vocal and instrumental techniques can also be used to make a statement without altering the lyrics of a song. For example, José Feliciano’s version of “The Star-Spangled Banner” and Marvin Gaye’s interpretation were more than the ritualistic performance of the national anthem at a sporting event (Dyson, 2004). Both used the vocal inflections and rhythms of their communities to turn the national anthem into a political and personal statement (Dyson, 2004). Instrumental music can also convey messages without words. In 1963, John Coltrane recorded “Alabama,” an instrumental jazz composition that criticizes violence against African Americans in Alabama or as a tribute to civil rights activists (Ratliff, 2008). Two of the most foundational musical genres in Puerto Rico are bomba and plena. Both are African-based musical and dance practices (Dufrasne González, 2018; Flores, 2000; Quintero Rivera, 2009). Both bomba and plena are rooted in the complex history of the island and have influenced other popular genres and musical fusions (Quintero Rivera, 2009). As Dorsey (2010) wrote, bomba is “a musical form that African captives brought to Puerto Rico in the 17th century” (p. 41). According to the ethnomusicologist Dufrasne González (2018), the characteristic rhythm of plena is a reinterpretation of subgenres of bomba using hand drums, instead of its typical barrellike drums. Plena is usually played by three hand drums of different sizes and pitches that could be described as being like tambourines without the jingles. Each drum plays a different pattern that, when played simultaneously, creates the kind polyrhythms known as plena. Other minor percussion instruments such as the guiro are © 2021 Hogrefe Publishing

common in plena (Martı́nez Tapia, 2017). Bomba music, on the other hand, is performed with at least two rather heavy drums: the buleador and the subidor (Quintero Rivera, 2009). The low-pitched subidor plays an African-based rhythm pattern while the higher-pitched subidor improvises (Quintero Rivera, 2009). The drums used for bomba are larger and heavier than the ones the reader might see in a salsa orchestra. Musical performances can be classified somewhere along a spectrum between participatory and presentational (Turino, 2008). Both bomba and plena are usually participatory. Bomba might be more participatory than plena as it subverts the musician–dancer relationship. Instead of the musicians imposing rhythmic patterns to which dancers must adjust, bomba dancers lead the “solo” played by the subidor. Furthermore, both bomba and plena include call-and-response, a fundamental element of African music that the diaspora brought to America. As Gioia (1997) wrote, “call-and-response forms that predominate in African music as well as in the work song, the blues, jazz and other Americanized strains of African music . . . reflects a culture in which the fundamental Western separation of audience from artist is transcended” (p. 9). Calland-response in plena and bomba usually occurs when the lead voice sings or speaks a verse and the chorus or the audience sing or shout back a specific response. On picket lines in Puerto Rico, it is fairly common to see musicians playing one or more of the plena hand drums while organizers or people who are part of the picket line switch between the lead voice and the chorus. In African-based Puerto Rican popular music such as bomba and plena, meaning is conveyed through lyrics, the knowledge and affects Puerto Ricans acquire about these genres throughout their socialization, and the degree of participation between performers and audiences. Lyrics rely on and create discourse and narrative about the world and current events. As we discuss below, both bomba and plena have played an important role in the history of Puerto Rico as means of transmitting messages to others. Schools in Puerto Rico play a role in the acquisition of knowledge about and affects toward bomba and plena. Both genres, while defined as popular music for being part of the local folk traditions (Flores, 2000) and being regularly played during holidays and festivals, would probably not be considered popular if we were able to measure how much they are played on the radio on nonholidays. Yet, once a year, in November, schools in Puerto Rico celebrate La Semana de la Puertorriqueñidad (which literally translates to the week of Puerto Rican-ness). Children learn about the history of Puerto Rico and its music in a more enjoyable and active way by taking part in plays and dances (Gómez, 2014). Furthermore, the performance of bomba and plena International Perspectives in Psychology (2021), 10(1), 3–12

T. Espada-Brignoni & F. Ruiz-Alfaro, Culture, Subjectivity, and Music in Puerto Rico

socializes in children and later reinforces in adults the collectivistic features of Puerto Rican culture by inviting them to collaborate in highly participatory musical practices.

The Role of Bomba and Plena in Collective Organization Puerto Rico is commonly referred to—by locals and visitors alike—as the enchanted island. However, this paradise in the Caribbean—at least for those who can afford to live there (Klein, 2018)—has been plagued with corruption and social injustice. Puerto Rico is an archipelago in the Caribbean consisting of the largest of the islands, called Puerto Rico, two island municipalities (Vieques and Culebra), and several small islands and islets not suitable for “regular” habitation. According to the US Census (2019), the median household income in 2014–2018 in Puerto Rico was $20,166, with 43.1% of people living in poverty. Specifically, for the summer of 2019, the census estimated a population of 3,193,694 in Puerto Rico. It is estimated that 98.9% of the population identifies as Hispanic or Latino origin and 67.4% consider themselves White. Interestingly, this racial identification has been a source of controversy since it invisibilizes the complex fusion of Indigenous, African, and European heritage that makes up the diverse biological, cultural, and psychological features of Puerto Ricans (Alleyne, 2005; Baerga, 2015). The classification of Puerto Ricans in discrete and mutually exclusive cultural categories is probably an impossible task. Racial and social categories such as, for example, the concepts used in the United States fail to grasp the processes of domination and racialization and the cultures that have emerged in Puerto Rico. As Alleyne (2005) suggested about the history of Puerto Rico during the 18th and 19th centuries, more social mixing thus seems to have taken place between different groups on the island than is considered to have been the case in other areas of the Caribbean. This led to a spread of cultural forms through the different ethnic (and social) groups, resulting in a Puerto Rico that is more culturally homogenous than other Caribbean societies (Alleyne, 2005, pp. 117–118). This should not be taken to mean that Puerto Ricans are a homogenous group or that there is no racism in the archipelago (Alleyne, 2005; Baerga, 2015). Rather, the historical scaffolding from which contemporary Puerto Rican subjectivities emerge is a complex blend of Indigenous, African, and European cultures through hundreds of years of colonization (González Rivera, 2006; Picó, 1986). In Negociaciones de Sangre, Baerga (2015) explored in great International Perspectives in Psychology (2021), 10(1), 3–12

detail the formal and informal practices through which the groups that inhabit Puerto Rico have been racialized. In his influential article “Social Psychology as History,” Gergen argued that social psychology “is primarily an historical inquiry . . . it deals with facts that are largely nonrepeatable and which fluctuate markedly over time” (1973, p. 310). The “contemporary affairs” (Gergen, 1973, p. 316) we study are grounded in the philosophies and collective representations that support the discourses and practices of a culture. A psychology as “historical inquiry,” as Nisbett (2004) analyzed in The geography of thought and as Nisbett and Cohen (1996) thoroughly showed in Culture of honor, is grounded in the collection of beliefs about the world and the relations among its elements (whether human or nonhuman, organic or inorganic). Cultural patterns survive geographical displacements and centuries of technological change when patterns of socialization reinforce the beliefs and actions of that group. Seeing as Puerto Rico is the outcome of the combination of several cultures, attempting anything near what Nisbett and Cohen accomplished in Culture of honor seems a bit unlikely, especially under the current circumstances. The relationship between history and psychology can also be found in how some historians rely on psychological concepts to characterize a population. For example, throughout the book Historia general de Puerto Rico, one of Puerto Rico’s most famous historians, Picó (1986), employed psychological concepts, making claims about Puerto Rico’s past and present residents. For example, he suggested that the so-called extended family and the bonds it promotes are critical in Puerto Rico precisely because, during the 18th and 19th centuries, these connections were fundamental to the survival of the individual and the community given the scarcity of resources and land (Picó, 1986). If music means something, it is precisely because it has the potential to promote, reinforce, or question the discourses and narratives that mediate the relationship between the individual and the world. In the case of the recent protests, it connected the people of Puerto Rico to each other, its past, and its hopes for a better future. The same ideas can be applied on the individual level. Furthermore, the protests of the summer of 2019 did not occur in a vacuum. As Klein (2018) acknowledged, “Puerto Rico has a deep history of popular resistance and some very radical trade unions” (p. 46). Yet, she described responses to recent privatization and the austerity policies of the past decade as “somewhat muted” (Klein, 2018, p. 46) due to several “doses” of what Klein (2018) calls “the shock doctrine” (p. 47). Klein’s ideas are not uncommon among scholars who focus on the colonial status of Puerto Rico (officially an unincorporated territory of the United States); however, © 2021 Hogrefe Publishing

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they cannot be extrapolated directly to the activities of Puerto Ricans in their everyday and cultural life. As Flores (2000) noted, traditional notions about colonization, while politically useful, fail to grasp at the individual and cultural level how individuals live and experience their reality. We would argue that, if there have been “muted” responses to privatization and austerity, a key element in the attempt to explain the lack of protests could be related to the narrative aspects of subjectivity. Massive strikes and protests in Puerto Rico, and perhaps elsewhere, are sparked by events that are interpreted as so exceptional that they are emotionally unbearable. The massive protest demanding that the US Navy leave the island municipality of Vieques (after decades of using large portions of the island for military training) began after the accidental death of David Sanes, a local security guard, during an exercise. People had resisted the occupation of parts of Vieques for decades, yet massive protests began only after Sanes was killed (McCaffrey, 2002). The case of Vieques (1999–2000) and the protests of the summer of 2019 were massive because specific events (the death of a civilian in 1999 and the contents of the leaked chat in 2019) proved too exceptional. These events then taxed the narrative (Bruner, 1990) and emotional (PichonRivière, 1985) aspects of Puerto Rican subjectivity. However, the higher-level discourses about the relationship between the United States and Puerto Rico probably changed very little. Political resistance can take many forms, and both bomba and plena are rooted in the history of resistance to the government in Puerto Rico as well as efforts to communicate and negotiate meanings about the state of affairs. For example, in the summer of 1826, José Juaquı́n sang a bomba to disseminate a plan to flee to Haiti and invite fellow slaves in Puerto Rico to join him (Baralt, 2006). As several scholars have noted, the use of bomba dances was one of Puerto Rican slaves’ preferred methods to express their emotions, organize rebellions, and disseminate plans to flee to Haiti (Baralt, 2006; Quintero Rivera, 2009). Plena was also used by local musicians to recite the news of the day and satirize local politicians (Tapia, 2017). In a way, it served some of the functions of a popular or grassroots newspaper. Bomba and plena are also tools the Puerto Rican diaspora uses to support their community and promote practices of resistance (Flores, 2000). To assert their support for local cultural projects, a Puerto Rican community in New York organized events that featured music from Puerto Rico as well as other genres from the Caribbean popular among Puerto Ricans. As Flores (2000) wrote, “Four hours of live music are interrupted only by further announcements . . . by far the most common favorite were bombas and plenas” (p. 67). Furthermore, © 2021 Hogrefe Publishing

during the protests in Vieques, musical pickets throughout Puerto Rico used plena to ask the Navy to leave (McCaffrey, 2002). From sports tournaments to festivals, weddings, and concerts, there is a selected group of songs that have proven to be collective anthems of Puerto Rican culture. The first measures and beats of Rafael Hernández’ “Preciosa” (Tapia, 2017)—as sung by Marc Anthony—can produce an immediate reaction in Puerto Ricans, exemplifying the intergenerational transmission of collective bonds through culture and music. In the context of social manifestations and protests, there are specific melodies and choruses that have been shouted through the streets, encompassing the emotions of social injustice. From the Vieques protests (1999–2000) to the summer of 2019, the chorus of “Enchumbao enchumbao, pero nunca arrodillao” brings a voice that shows how even when the people are soaked by the rain and uncomfortable, they will not kneel to the government’s injustices. This chorus also characterizes the duress the people on the streets during the protests endure through the unpredictability of the tropics. Another chorus that has roared through many manifestations for the past few decades is produced by questioning the absenteeism of the governor in addressing the social injustices endured by Puerto Ricans and recognizing the government’s corruption and selling out to promote imperialistic agendas. This chorus is “performed” in a calland-response pattern where an individual inquires about the location of a political figure and the crowd responds. The chorus, “¿Y donde está (governor’s name)? (governor’s name) no está aquı́, (governor’s name) está vendiendo lo que queda del paı́s,” refers to how the governor is selling what is left of the archipelago, disregarding Puerto Ricans’ rights, and perpetuating corruption.

The Summer of 2019 The events of the summer of 2019 in Puerto Rico were by all accounts unprecedented although the conditions leading to their eruption had been brewing for years, decades, and even centuries. An anonymous source leaked to the Centro de Periodismo Investigativo a chat led by Ricardo Rosselló, then governor of the island. The hundreds of pages of the chat transcript were a sample of what Ricardo Rosselló and his close friends thought about women, members of the LGBTTQ community, and the thousands who lost their lives during and in the aftermath of the devastating Hurricanes Irma and Marı́a, which tore through Puerto Rico. The chat also revealed how government officials dealt with their political opponents through the manipulation of the media, transforming how International Perspectives in Psychology (2021), 10(1), 3–12

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the governor and his work were depicted in the press. The Centro de Periodismo Investigativo published the chat on July 13, 2019 (Valentı́n Ortiz & Minet, 2019). After its publication, hundreds, then thousands, of Puerto Ricans protested in the streets. People from all backgrounds organized organically to demand the governor’s resignation. From social media hashtags to memes and lyrics, these protests were like no others before. The protests of the summer of 2019, like many contemporary social movements, exceeded the definitions and biases of the first scholars, such as Gustav Le Bon and Sigmund Freud, who theorized about the nature of crowds (Gerbaudo, 2012; Moscovici, 1985). The protests of 2019 could reveal some of the fundamental elements of what could be considered a collective Puerto Rican subjectivity, particularly because they may have marked the first time a divided society came together with one specific political goal: the resignation of the governor. Based on an analysis of the narratives of the many images, chants, and expressions of the people during the protests, it was mainly two things that brought people together: the chat’s disrespectful comments about the dead and the use of art as a way of constructing a discourse about the government and the demands of the people. Both proved to be exceptions in the narrative Puerto Ricans have constructed about themselves. During the protests, many carried signs expressing their indignation and anger about the way participants in the chat had talked about the lives lost after the hurricanes. In a sense, they were once again mourning the people they had lost almost 2 years previously. Once Rosselló announced his resignation, some brought to the next protests signs saying that the people who had died could now finally rest in peace. His resignation gave some sense of closure to the people after the leaked chat resurrected the trauma of their struggles on the island in the aftermath of the hurricanes of 2017. Music also played an important role during the protests as well as a coping mechanism during the aftermath of Hurricane Marı́a. Espada-Brignoni (2019) has already described in another article how communities used music to bring people together and manage their suffering collectively, highlighting how, in contexts of crisis, music was one of the most important resources in Puerto Rico. During the protests, music played an important role in bringing people together and arguably encouraged those who were unsure about whether to go out into the streets and protest to join the marches and picket lines. If we think of these events as a prompt by a psychologist using free association, one of the first “responses” by our collective is the use of popular music, including bomba and plena, to express anger, frustration, and hope. The chants and chorus used during the protests, some from decades of International Perspectives in Psychology (2021), 10(1), 3–12

protests and others improvised, were based on the calland-response pattern fundamental to African music, which influenced Puerto Rican popular music (Malavet Vega, 1992). Understanding the complex roots of bomba and plena is essential for any psychologist attempting to understand Puerto Rican subjectivity. Dorsey underscores the hybrid nature of Puerto Rican culture while problematizing the question of origin, for different groups from Africa influenced it heavily and trying to pin down the one responsible for a specific cultural element may be almost impossible. As Moreno Vega (1999) writes, “In Puerto Rico, as in other plantation societies, Africans brought their sacred world to the Americas, accommodating them to the horrific conditions of enslavement and oppression” (p. 327). Furthermore, “ancestor worship within Puerto Rican culture is one of the persistent cultural practices that continues to infuse an African worldview into the larger Puerto Rican community” (Moreno Vega, 1999, p. 334). For these reasons, the jokes about the dead in the governor’s chat were incredibly hurtful to the people of Puerto Rico. The number 4,645, which indicates the number of people who died in the aftermath of the hurricanes, as a study by Harvard reported, became important in the protests and in one of the songs recorded to demand Rosselló’s resignation (BBC News Mundo, 2019). How individuals understand death is deeply embedded in their culture and plays an important role in how they manage loss and grief. Common sense, the media, and some psychologists dictate that dramatic and individual cases yield more empathy than large abstract numbers of victims (Bloom, 2018). Such a belief is reinforced when, to convey a sense of urgency, the most terrifying images of individual victims are displayed intentionally, both promoting and reproducing very narrow empathic bonds with others. On the other hand, Olson (2013) argues that what seem to be evolutionary dispositions toward empathy are superseded by the political and economic structures in which we live. The events of the summer of 2019 seem to be an exception to the “rule” described above. Insight from the cross-cultural comparisons of collectivistic and individualistic cultures, however, could explain why, in Puerto Rico, the otherwise abstract number provided by researchers proved more powerful and significant than individual cases. According to the social orientation hypothesis, “Individualistic societies view people as agentic,” and collectivistic societies are more “mold thinking into more context-focused, relational patterns found in dialecticism” (de Oliveira & Nisbett, 2017, p. 785). The kind of society in which individuals grow up deeply influences how they think about themselves as well as how they interact with the environment (de Oliveira & Nisbett, 2017). © 2021 Hogrefe Publishing

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Musical practices serve to reinforce these habits according to how participatory or presentational they are by scaffolding individualistic or collectivistic patterns of thought. It would make sense, then, that individualistic societies would respond better to single dramatic cases and, while people whose thinking is more dialectical, can also empathize or feel an emotional connection with more abstract representations of a tragedy. Drawing from ideas developed by the psychoanalyst Daniel Lagache, Pichon-Rivière (1985) argues that an individual’s creative expressions, such as those that yield art, can be considered to be part of a psychological field of analysis. Art, then, can be understood not only as an individual’s or group’s creative endeavors but also as a collective form of healing in which artists, serving as facilitators, leaders, and therapists, promote other ways of seeing and feeling. In the protests that erupted after Rosselló’s chat was leaked, the role of artists, which needs to be analyzed in more detail, was particularly interesting. Anyone who arrived at La Fortaleza (the governor’s mansion) would have seen people in body paint near or standing in the barricades. At the same time, within the multitude (at La Fortaleza and many other locations), many brought banners referencing the chat that criticized the governor, or drawings and paintings about the governor and the other participants in the chat. Others brought hand drums to play plena and use its rhythm for the protest chants. Renowned singers also showed their support for the protests and were part of the caravans. In a way, we could say the artists embodied one of the fundamental elements of leadership: the ability to represent the will of the collective (Haslam et al., 2011). They were not the “leaders” of the protests in the traditional sense of the term, but they helped amplify the will of the people. Thus, art can promote new and powerful bonds between individuals and the world. From a psychological perspective, it provides various creative modes of expression that allow individuals to bring meaning to their collective realities. Artwork cannot be considered an asocial or universal production; instead, it should be analyzed as an expression of a subjectivity embedded in a specific historical and social context (Carmona, 2004). Artists take on multiple roles through their careers and work; this includes incorporating their identities from both their collective and individual subjectivities in their work. As Pichon-Rivière (1985) explains, the roles that individuals assume in a given social situation can unconsciously include introjective and projective meanings, for instance, the complex analysis of any work of art: Embedded in the work of an artist is their subjectivity both from individual and collective constructing and problematizing identities. Perhaps the deep and underlying cultural expressions that resurfaced during these processes can be related, © 2021 Hogrefe Publishing

tentatively, to a couple of factors. First, in order for crowds to protest effectively, they imagine themselves as members of a larger identity that ties them together. How else can we explain hundreds of thousands of “strangers” cramped in the narrow streets of old San Juan, cooperating with one another? Second, the strong reference to Puerto Rican culture might indicate the generation or activation of transient subjectivations wherein individuals rely on their shared knowledge to work toward the same goals collectively. Even though Puerto Ricans have marched through the streets in protests many times before, this time it was different. During the summer of 2019, the subjective bonds individuals had with the official political leadership of the island were broken, creating an alternate, transient, and strong subjectivation that lasted a couple of weeks. Historical protests such as the civil disobedience that urged the US Navy to demilitarize Vieques (1999–2000), as well as recent manifestations with a national strike in 2009, students’ protests in 2010, what happened in 2013, and many others, have constructed the cultural subjectivity of the archipelago. Those social movements included thousands of individuals who marched in order to claim social justice for education and civil and economic rights, as well as an end to corruption. However, in the summer of 2019, people thought of themselves as a collective unit who had shared and survived a terrible trauma. This transient subjectivation is not a mere reaction to the chat; in fact, its most important components can be found only in the history and culture of Puerto Rico and the narrative aspects of subjectivity. The long-term effects of these protests will have to be carefully analyzed later, but it is worth noting a couple of things. After Rosselló’s resignation, the protests gradually weakened even though Rosselló’s successor was part of his administration. Both detractors and supporters of the protests started using the concept of “Verano del 2019,” which translates to “Summer of 2019,” to refer to the manifestations. The phrase “la generación del yo no me dejo,” which made it into a song, can be loosely translated to “the generation that can’t be messed with” and marks a change in the narrative Puerto Ricans at large are conceiving of themselves and their bonds to social and political institutions as well as of a split with previous forms of participation in politics. This might not be translated into action every time the public faces similar challenges, but some aspects of the transient subjectivities that emerged during the summer of 2019 will probably resurface under the appropriate conditions. One example of this is the number of people from different parts of the island who, in the aftermath of the 6.4 magnitude earthquake in January, bought and delivered supplies to the people suffering the most. Their distrust of the current government generated International Perspectives in Psychology (2021), 10(1), 3–12

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both spontaneous and organized caravans of Puerto Ricans rushing to help the most vulnerable (Datil et al., 2020; Telemundo, 2020).

History, Culture, and Subjectivity Through approaches ranging from theoretical conceptualizations to neuroimaging techniques, psychology has tried to understand the many feelings and emotions that music evokes in the individual and in the collective (Tan et al., 2010; Thompson, 2015). From understanding a collective reality to understanding the individual, music distances itself from a dichotomous perspective, allowing plural meanings that can be diverse and paradoxical. Pichon-Rivière (1985) argues that the bonds we establish with other subjects and objects can only be understood from a social viewpoint. The same can be applied to understanding the intergenerational transmission of a collective identity through music. Music transcends many barriers, including those that arise when words fail to capture feelings and emotions. Puerto Rican folklore is experienced through childhood from symbolic patriotic representations such as the Puerto Rican flag, classic country person such as the jibaro as a main character in various poems, stories, songs, and paintings. The commemoration of a commonwealth holiday on November 19 which through the Semana de la Puertorriqueñidad provides an assertion of local culture. During this week, children from all ages dress in traditional Puerto Rican clothes, and schools all over the archipelago produce a talent show that provides an homage to our Puerto Rican identity from bomba and plena singers and dancers to culinary creations that pay tribute to our ancestors. It is precisely for these reasons that we can consider the use of popular music to be a vehicle for a collective subjectivity: It allows groups to access emotions and experiences that go beyond the limits of spoken discourse, for the perception is that words fail to capture the intensity of the experience. An example of this was organically conceived through the Puerto Rican summer of 2019. Music offers an inherent cultural bond to a particular historical and political context. The sense of belonging associated with the first sounds that emerge from a plena or bomba song proves that these genres translate nationality through musical notes. From a historical perspective, people who made music in Puerto Rico turned their suffering into songs (Malavet Vega, 1992). From an ethnographic perspective, it has been argued that plena musicians can consider themselves to be guardians of cultural identity, responsible for the authenticity of this International Perspectives in Psychology (2021), 10(1), 3–12

Puerto Rican musical legacy (Guerrero, 2013). As scholars like Gennari (2006) and Provost (2017) and musicians like van Ronk (2006) have pointed out, however, relying on essentialist notions of authenticity is problematic, for they can be used to force individuals to fit within specific narratives and identities, instead of allowing subjectivities and culture to evolve. Culture, the self, and the bonds that individuals develop with their world are embedded in complex relationships and evolve over time. Psychologically, bomba, plena, and popular music provide rich material for the in-depth analysis of the subjectivities and behaviors that are promoted, reinforced, and problematized in Puerto Rico. Puerto Rican subjectivity has also been intertwined with official discourses about race (Abadı́a Rexach, 2018; Baerga, 2015) and how traditional historiography has constructed the story of the relations between different groups on the island (Baerga, 2015; Picó, 1986). For decades, children in schools learned a watered-down version of Puerto Rican history that attempted to frame what it meant to be Puerto Rican as the almost peaceful combination of Taino, Spanish, and African culture. Of course, our history was far from peaceful, and the country was built using slave labor and, subsequently, through plantation owners’ exploitation of the descendants of former slaves and the island’s poorest people. In this context, Dorsey (2010) argues, “African captives were people who, as individuals and groups, played major roles in the shaping of Puerto Rican history and culture” (p. 44). Unfortunately, as Moreno Vega (1999) argues, the legacy of African culture in Puerto Rico has been mostly ignored. Many elements of African culture, however, persist and influence our psychology. The melodies and rhythms of bomba and plena, developed within this context of oppression, paved the way for combative momentum, as well as for what Fabian calls “moments of freedom” (1998, p. 138) that popular culture can bring forth for those striving to create a better world.

Conclusion Psychological theory and practice must always understand and be rooted in the culture and history of the individuals or groups it studies. Both the collective past and the individual past provide the necessary scaffolding for the self and for individuals’ interactions with the world. Bringing in-depth and nuanced discussions about culture and history could foster a cosmovision of ethnicity as a complex, multilayered process rather than a simple variable that must be controlled to make sense of the data. In this article, we used music in an attempt to explore the complex © 2021 Hogrefe Publishing

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web of relations among culture, history, and psychology. The creative nature of music, or any other art form, reveals not only the resources of an individual artist but also the underlying elements of a collective consciousness. Our aim is not to build from scratch a new model of the subject; instead, we attempt to join in the efforts and discussions brought by Enrique Pichón-Rivière as well as the reflexive contributions from indigenous and social psychology to grasp the complex relationship between history, culture, and psychology. Bomba and plena, among other cultural practices, are the pretext and some of the materials we need in order to promote an in-depth understanding of our culture and subjectivity. Unlike other musical practices, bomba and plena emphasize the connection between Puerto Rican’s indigenous roots. In Puerto Rico, natural and social disasters spark the collective and creative spirit of what it means to be Puerto Rican, and as it was portrayed through that summer of 2019, music roars for a collective subjectivity. Music gave Puerto Ricans new hope. On July 24, 2019, after decades of government corruption drained the fighting energy of generations of Puerto Ricans, various forms of music gave meaning to a new generation of individuals who collectively created a cultural identity that had to be heard. After approximately 12 days of massive manifestations from diverse groups in the island, governor Ricardo Rosselló stepped down from his position as the governor of Puerto Rico. While many have analyzed the uses of popular music as ways to distract people from politics, bomba and plena have once again highlighted the social and psychological bonds that unite Puerto Ricans together. We hope that these rhythms we inherited from our African ancestors continue to light our way and narrative toward more an intentional construction of a more democratic future.

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Guerrero, P. (2013). A story told through plena: Claiming identity and cultural autonomy in the street festivals of San Juan, Puerto Rico. Island Studies Journal, 8(1), 165–178. https://www.islandstudies. ca/sites/islandstudies.ca/files/ISJ-8-1-2013-Guerrero.pdf Haslam, S. A., Reicher, S., & Platow, M. J. (2011). The new psychology of leadership: Identity, influence, and power. Psychology Press. Hook, D. (2007). Foucault, psychology and the analytics of power. Palgrave Macmillan. Kim, U., & Park, Y. S. (2006). The scientific foundation of indigenous and cultural psychology: The transactional approach. In U. Kim, K. S. Yand, & K. K. Hwang (Eds.), Indigenous and cultural psychology: Understanding people in context (pp. 27–48). Springer. https://doi.org/10.1007/0-387-28662-4_2 Kim, U., Yang, K. S., & Hwang, K. K. (2006). Contributions to indigenous and cultural psychology: Understanding people in context. In U. Kim, K. S. Yand, & K. K. Hwang (Eds.), Indigenous and cultural psychology: Understanding people in context (pp. 3–25). Springer. https://doi.org/10.1007/0-387-28662-4_1 Klein, N. (2018). The battle for paradise: Puerto Rico takes on the disaster capitalists. Haymarket Books. Lemke, T. (2019). A critique of political reason: Foucault’s analysis of modern governmentality. Verso. Lomotey-Nakon, L. L. (2018). Du Bois’s decolonial pragmatism: Teaching community psychology toward epistemological liberation. American Journal of Community Psychology, 62(3/4), 364–373. https://doi.org/10.1002/ajcp.12289 McCaffrey, K. T. (2002). Military power and popular protest: The U.S. Navy in Vieques, Puerto Rico. Rutgers University Press. Malavet Vega, P. (1992). Historia de la canción popular en Puerto Rico (1493–1898). [History of popular music in Puerto Rico (1493–1898)]. Editora Corripio. Mattern, M. (1998). Acting in concert: Music, community, and political action. Rutgers University Press. Martı́nez Tapia, R. (2017). El espı́ritu de la música borincana: Percusión, tradición y cultura. [The spirit of Puerto Rican music: Percussion, tradition, and culture]. Editorial de la Universidad de Puerto Rico. May, T. (1993). Between genealogy and epistemology: Psychology, politics, and knowledge in the thought of Michel Foucault. The Pennsylvania State University Press. Moreno Vega, M. (1999). Espiritismo in the Puerto Rican community: A new world recreation with the elements of Kongo ancestor worship. Journal of Black Studies, 29(3), 325–353. https://doi.org/10.1177/002193479902900301 Moscovici, S. (1985). The age of the crowd: A historical treatise on mass psychology (J. C. Whitehouse, Trans.). Cambridge University Press. Nelson, K. (2007). Young minds in social worlds: Experience, meaning, and memory. Harvard University Press. Nisbett, R. E. (2004). The geography of thought: How Asians and Westerners think differently. . .and why. Free Press. Nisbett, R. E., & Cohen, D. (1996). Culture of honor: The psychology of violence in the South. Westview Press. Oberprantacher, A., & Siclodi, A. (2016). Introducing a contorted subject called “subjectivation”. In A. Oberprantacher & A. Siclodi (Eds.), Subjectivation in political theory and contemporary practices (pp. 1–24) [Ebook]. Palgrave Macmillan. https://doi. org/10.1057/978-1-137-51659-6 Olson, G. (2013). Empathy imperiled: Capitalism, culture, and the brain. Springer. https://doi.org/10.1007/978-1-4614-6117-3 Parker, I. (1996). Discurso, cultura y poder en la vida cotidiana. [Discourse, culture, and power in everyday life]. In A. Gordo-López & J. L. Linaza (Eds.), Psicologı́a, discurso y poder: Metodologı́as cualitativas, perspectivas crı́ticas (pp. 79–92). Visor.

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Pichon-Rivière, E. (1985). Teorı́a del vı́nculo. [Bond theory]. Nueva Visión. Picó, F. (1986). Historia general de Puerto Rico. [General history of Puerto Rico]. Ediciones Huracán. Provost, S. C. (2017). “Bringing something new”: Female jazz instrumentalists’ use of imitation and masculinity. Jazz Perspectives, 10(2–3), 141–157. https://doi.org/10.1080/ 17494060.2018.1443866 Quintero Rivera, A. G. (2009). Cuerpo y cultura: Las músicas «mulatas» y la subversión del baile. [Body and culture: Black music and resistance in dance]. Iberoamericana. Ratliff, B. (2008). Coltrane: The story of a sound. Picador. Riegel, K. (1976). Psychology of development and history. Plenum Press. Tan, S.-L., Pfordresher, P., & Harré, R. (2010). Psychology of music: From sound to significance. Psychology Press. Telemundo P. R. (2020). Viral: Captan enorme caravana con suministros en el suroeste. [Viral: They see enourmous caravan with supplies to the west]. Telemundo Puerto Rico. https://www. telemundopr.com/noticias/puerto-rico/viral-captan-enormecaravana-con-suministros-en-el-suroeste/2034713/ Thompson, W. F. (2015). Music, thought, and feeling: Understanding the psychology of music (2nd ed.). Oxford University Press. Turino, T. (2008). Music as social life: The politics of participation. Chicago University Press. US Census Bureau. (2019). Quickfacts: Puerto Rico. https://www. census.gov/quickfacts/fact/table/PR/IPE120218#IPE120218 Valentı́n Ortiz, L. J., & Minet, C. (2019). Las 889 páginas de telegram entre Rosselló Nevares y sus allegados. [The 889 pages of the telegram chat among Rosselló Nevares and his close ones]. http:// periodismoinvestigativo.com/2019/07/las-889-paginas-detelegram-entre-rossello-nevares-y-sus-allegados/ van Ronk, D. (2006). The mayor of McDougall street: A memoir. Da Capo Press. Varela, F. J., Thompson, E., Rosch, E. (2016). The embodied mind: Cognitive science and human experience. MIT Press. History Received March 2, 2020 Revision received June 22, 2020 Accepted October 27, 2020 Published online February 17, 2021 Authorship Some of the ideas in this article were presented by both authors in a presentation titled Music, Culture, and Psychology in Puerto Rico as part of Flow 2019: Ways of Knowing at Antioch College in Yellow Springs, OH, USA. Flow 2019 was in Ohio, but both authors were in Puerto Rico at the time and presented via Skype. ORCID Teó filo Espada-Brignoni  https://orcid.org/0000-0002-5295-9497 Frances Ruiz-Alfaro  https://orcid.org/0000-0003-4651-3189 Teó filo Espada-Brignoni Division of Social Sciences Antioch College 1 Morgan Pl Yellow Springs, OH 45387 USA tespada@antiochcollege.edu

Article

Development, Construct Validity, and Measurement Invariance of the Parasocial Relationship With Political Figures (PSR-P) Scale Moh Abdul Hakim1 and James H. Liu2 Department of Psychology, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia

School of Psychology, Massey University, Auckland, New Zealand

Abstract. Parasocial theory views ordinary people’s emotional bonding with political figures as a form of parasocial relationship (PSR). Despite the insights it offers, existing measures of PSR have been criticized conceptually and psychometrically. We developed a new scale of PSR with political figures (PSR-P) and examined the construct validity, factor replicability, and measurement invariance based on samples from culturally and politically diverse countries (i.e., Indonesia, New Zealand, and the United States). In three studies using a panel of experts (N = 20; Study 1), a convenience adult sample (N = 212; Study 2), and representative and cross-cultural samples (N = 897; Study 3), we found that the four-item PSRR scale provides satisfying construct validity, as well as a replicable factor structure and scalar invariance across countries. The PSR-P scale can be utilized to advance the measurement and application of parasocial theory in the field of social and political psychology. The policy implications of the findings are also discussed. Keywords: parasocial theory, parasocial relationships, political figures, measurement invariance, construct validation Impact and Implications. This study explores the phenomenon of people’s emotional bonding with political figures and proposes a newly developed scale to measure it as a form of parasocial relationships (the PSR-P scale). The brevity and the psychometric properties of PSR-P scale allow researchers and policymakers to assess the extent to which people’s PSRs with political figures impact the quality of democracy across countries with different political cultures. The results of the study suggested that, if not properly mitigated, people’s PSRs political figures may pose a significant risk to our attempt to build effective, accountable, and inclusive institutions at all levels (Sustainable Development Goal No.16, SDG-16), especially in the context of democracy.

The personalization of politics in the form of individuals’ personal bonding with political figures is regarded as one important feature of political behavior in contemporary democracies (Garzia, 2011, 2013; Lobo & Curtice, 2014; Schneider, 1994). Such political attachment is unique with respect to the current social and political psychology literature for several reasons. It has been described as (1) being little influenced by political ideology, but instead, it revolves around emotions (Lenz, 2013; Schneider, 1994). (2) Bonding with political figures also appears to depart from traditional institution-based political loyalty, such as party identity or partisanship (Lobo & Curtice, 2014). (3) It has been also observed that such personal bonding with figures entails certain motivational components that drive ordinary citizens to engage more in politics (Dunn & Nisbett, 2014; Gabriel et al., 2018).

Despite its salience in politics today, the kind of theoretical framework that can best explain people’s emotional attachments to political figures and the scale required to measure it remains open to question. Previous research has employed various theories and models to explain individuals’ tendency to form attachments with political leaders, including individual-based (i.e., authoritarian personality, Adorno et al., 1950; personality-congruency models, Caprara & Zimbardo, 2004), and group-based theories and models (e.g., the party identity model, Huddy et al., 2015). For instance, authoritarian personality theory tends to view such tendencies as a personality disposition that expresses the need to submit to strong, yet distant, leaders. On the other hand, a more group-oriented theory, such as the party identity model is likely to explain the phenomenon as the expression of one’s identification with

International Perspectives in Psychology (2021), 10(1), 13–24 https://doi.org/10.1027/2157-3891/a000002

a political party, including its leader. Although these models might have some merit, they might not capture the central psychological component of the personalization of politics, which is the symbolic personal closeness that ordinary people have toward political figures (see Garzia, 2013 for a review). In the present paper, we argue that people’s personal bonding with political figures could be better understood within the framework of a PSR model. Scholars in this field of media and entertainment psychology have long observed that individuals have the ability to form symbolic closeness with public figures, such as celebrities, sportsmen, and other popular characters. Such bonding has been conceptualized as a form of PSR. PSRs are defined as enduring, long-term, and positive, one-sided forms of relational intimacy that people develop toward public figures (e.g., celebrities, sportsmen, politicians; Dibble et al., 2016; Horton & Wohl, 1956; Klimmt et al., 2006). Borrowing this concept into the field of political psychology, we contend that people can also form the feeling of intimacy at the distance with public figures in political settings, and this feeling might have consequences in terms of political engagement and action. The main goal of the present article is then to empirically demonstrate the utility of this concept and the validity of the scale that we have developed to measure people’s PSRs with political figures, and how it might vary across countries as a function of different political cultures.

Parasocial Relationships The theory of PSRs builds on the idea that individuals have the ability to develop a one-sided or illusionary intimacy at distance with a public figure (or a persona) by viewing them through mass media over time (Horton & Strauss, 1957; Horton & Wohl, 1956). As Horton and Wohl (1956) put it, “They [the viewers] know such a person in somewhat the same way they know their chosen friends; through direct observation and interpretation of his appearance, his gesture and voice, his conversation and conduct in a variety of situations” (p. 216). Further, they posited that the social psychological processes involved in PSRs mirror those in real interpersonal relationships (e.g., friendships; Horton & Strauss, 1957). Research has found that people who are in a PSR regard the figure of intimacy as a source of comfort and enjoyment as well as a role model (Giles, 2002; Gleason et al., 2017). They are also motivated to actively nurture the relationship (Horton & Wohl, 1956; Rubin & Mchugh, 1987) and even experience grief and loss when the figure disappears (e.g., dies, withdraws from the public life, and so forth; Cohen & Hoffner, International Perspectives in Psychology (2021), 10(1), 13–24

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

2016; Eyal & Cohen, 2006). Unlike real interpersonal relationships, however, PSRs with public figures like celebrities and political candidates elicit asymmetry, where the fans typically exhibit a strong admiration to the figure, but this is not equally reciprocated by the public figure (Horton & Strauss, 1957; McCutcheon et al., 2002).

PSRs and Parasocial Interaction In early developments of the construct, there were ambiguities concerning the conceptualization and measurement of PSR and its preceding process, which is parasocial interaction (PSI). In their seminal work, Horton and Wohl (1956) put forward the concept of PSR to describe the long-term one-sided intimacy at distance that a viewer developed toward media figures (or personae). Unfortunately, this term was often used interchangeably with the notion of PSI, which refers to imagined interactions that the viewers have with media figures during media exposures (e.g., responding to a protagonist actor when watching a movie on television; Horton & Strauss, 1957; Horton & Wohl, 1956). Considering the proximity of these two phenomena, Rubin and colleagues (Rubin & Mchugh, 1987; Rubin & Perse, 1987) proposed a broader definition of PSI that considers both the interaction and the relationship as a single phenomenon. This operational definition was then used as the conceptual basis for the development of Rubin et al.’s PSI scale (Rubin et al., 1985). More recently, however, most media psychologists have agreed that PSR and PSI should be treated as two independent constructs (Dibble et al., 2016; Giles, 2002; Klimmt et al., 2006). They argue that, though the two phenomena are related, PSI and PSR differ theoretically in several meaningful ways. In terms of the nature of the constructs, it is argued that PSI stands for a mediabounded phenomenon in which the viewers experience a simulacrum of conversational give-and-take as a response to a media figure in media exposure situations (Giles, 2002). In contrast, a PSR refers to a one-sided and positive relationship that extends beyond the media exposure situation (Dibble et al., 2016; Schramm & Wirth, 2010). Importantly, not all PSIs with a media figure translate to PSRs. Such might be the case, for instance, when a given figure is disliked by the viewers (Giles, 2002). Considering these distinctions, Hartmann et al. (Dibble et al., 2016; Klimmt et al., 2006; Schramm & Hartmann, 2008) suggest that PSR should be explicitly defined as the enduring and cross-situational feeling of intimacy at distance with a media or public © 2021 Hogrefe Publishing

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

figure. Consequently, alternative measures that are primarily designed to assess PSRs are needed (Schramm & Wirth, 2010), especially in the context of PSRs with political figures.

Measuring Parasocial Relationships With Political Figures Previous studies have used and modified the PSI scale to measure peoples’ symbolic intimacy with political figures and their correlations with various political outcomes. Dunn and Nisbett (2014) modified 12 items from the short version of the PSI scale (Rubin & Perse, 1987) to assess PSI with political candidates on webpages and social media. Additionally, they selected and modified five items (e.g., the webpage shows me what this candidate is really like: when I viewed the candidate webpage, I felt like part of a group, I see this candidate as a natural, down to earth person, this candidate understands what I need, and this candidate understands what I want) to measure perceived intimacy during the candidate’s webpage viewing for the reason that these items describe perceptions of a reciprocal relationship. A slightly different approach was taken by Cohen and Holbert (2018), whereby they selected 12 items from the long version (20 items) of the PSI scale (Rubin et al., 1985) in devising the political PSR (PPSR) scale to measure the feeling of connection to several political figures, including Donald Trump, Hillary Clinton, and Paul Ryan. Interestingly, three items of this PPSR scale were almost identical to those of Dunn and Nisbett’s (2014) measure of perceived intimacy with political candidates during the media exposure (i.e., when I’m watching Donald Trump; I feel as if I am part of his group, I see Donald Trump as a natural, down-to-earth person; Donald Trump seems to understand the kinds of things I want to know). Moreover, two items seem to be closely relevant to the imagery interactions in a media exposure situation rather than to the enduring feeling of intimacy with the figures (e.g., when Donald Trump expresses how he feels about the news, it helps me make up my mind about the media; I like to compare my ideas with what Donald Trump says). These seemingly diverse interpretations of the PSI items might, in fact, stem from Rubin et al.’s broad definition, albeit conceptually problematic, of PSI, which also incorporates PSR (Dibble et al., 2016; Klimmt et al., 2006). The problem is, neither scale is exclusively devised to focus on the enduring feeling of emotional intimacy that people have toward political figures. Given this conceptual lack, an alternative measure designed specifically to measure PSR with political figures (PSR-P) is © 2021 Hogrefe Publishing

needed. We developed an alternative scale of PSR-P that explicitly measures the enduring feeling of intimacy with a political figure. This scale was devised based on Horton and Wohl’s (1956) original conception of a PSR and its contemporary refinements by Hartmann et al. (Dibble et al., 2016; Hartmann & Goldhoorn, 2011; Klimt et al., 2006; Schramm & Hartmann, 2008). In political contexts, the newly developed PSR-P scale may be utilized as a complement to existing Schramm and Hartmann’s (2008) 13 item PSI Process (PSI-P) scale as modified by Gabriel et al. (2018) and was reported to be significantly associated with positive attitudes and trust to the figure, as well as believing in the candidate’s promises and voting for them (Gabriel et al., 2018). PSI and PSR are both important, but empirically separable components of the examination of a feeling of intimacy with distant others through mass media.

Cross-Country Differences Between New Zealand, the United States, and Indonesia Political scientists have argued and provided evidence that the degree of the personalization of politics may vary across countries. More specifically, some political scholars (Garzia, 2011; Lobo & Curtice, 2014; Rahat & Kenig, 2018) have pointed out two contextual factors that may influence people’s propensity to get attached to political figures, namely, the type of political system (i.e., parliamentary vs. presidential) and the level of democratic maturity (established vs. emerging democracy). In countries with parliamentary systems like New Zealand, people never actually vote directly for the candidates for prime minister; instead, they vote for the parties that hold the authority to select the prime minister. Therefore, in parliamentary systems, people and news media are more likely to focus their attention on the parties and their policies instead of the individual candidates, constraining voters from developing a strong emotional bond with the candidates. In contrast, in presidential systems, it is the individual presidential candidates that are most likely to attract news media’s and people’s attention in every general election. Candidates directly receive votes. Research studies have shown that, in countries with presidential systems like United States and Indonesia, the ability of the individual candidates to build an emotional connection with their constituents plays a major role in their chances to get elected (Gabriel et al., 2018; Mietzner, 2015). Consequently, it makes sense to expect that people in countries with presidential systems are more likely to have stronger International Perspectives in Psychology (2021), 10(1), 13–24

PSRs with political figures compared to their counterparts in parliamentary systems. The second important contextual factor is the degree of democratic maturity. Established and emerging democracies differ substantially in terms of the role and the strength of the political party in political processes (Tsebelis, 2002). In countries with established democracies such as the United States and New Zealand, political parties are typically well organized and strongly rooted in various socioeconomic and cultural groups in the society (e.g., religious and ethnic groups, workers unions, etc.). Within such political contexts, people are more likely to develop loyalty to the party as an organization rather than to individual political leaders (Campbell et al., 1980). On the other hand, political parties in emerging democracies like Indonesia are generally weak and have to depend so much on their leaders and other popular figures to attract support from voters. Given this, it is reasonable to expect that people in emerging democracies would tend to be more likely to develop PSRs with political figures than their counterparts in established democracies. Taking the type of political system and the level of democratic maturity into account, a good scale of PSRs with political figures, thus, should demonstrate the ability to reliably measure the variances of PSRs across countries with differences in these contextual factors (Hambleton & de Jong, 2003).

The Need for a Short Scale The comparative and cross-national nature of research in the field of the personalization of politics demands a short psychological scale to measure people’s PSRs with political figures. There are at least three advantages of developing and using short scales in political research that typically require large and representative samples from different groups in the society (Ziegler et al., 2014). First of all, the brevity of short scales will significantly reduce the respondents’ burden to take part in a survey, so that the response rate and statistical power of the study can be optimized (National Research Council, 2013). Second, short scales will allow researchers to incorporate more constructs in their survey, which are often needed when one intends to study complex phenomena, as is often the case in political science and political psychology (Ziegler et al., 2014). Finally, a brief scale is also preferred when one aims to assess a simple and unidimensional construct like the PSR with a political figure. Of course, there are also some potential shortcomings of using short scales, namely, that the few numbers of items in short scales might lower the internal reliability (e.g., Cronbach’s α) and criterionInternational Perspectives in Psychology (2021), 10(1), 13–24

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

related validities. However, these consistency- and validityrelated problems can be mitigated if the development of the scale is systematically carried out (Kruyer et al., 2013) in accord with its usages: the PSR-P is not designed to assess criteria for individual decision-making (like a depression scale used by a clinician), and so it is fit for purpose.

Study 1: Development and Content Validity of the PSR-P Scale In the current study, we aimed to develop an item list for the PSR-P scale and to conduct a content validation with a panel of experts. In developing the scale, we relied heavily on the theoretical work of Horton and Wohl (1957) and Klimmt, Hartmann, & Schramm (2006) to operationally define PSRs with a political figure as an enduring and cross-situational feeling of intimacy at distance that an ordinary person holds for a political figure. We used four criteria in generating the items: first, the items should tap into the socioemotional aspects of PSRs with political figures. Second, the wording of the items should be simple and straightforward so that they can be easily translated into different languages. Finally, the items should also have the accuracy to reflect lay people’s everyday experiences in politics. In the process of the scale development, we first reviewed the Rubin et al.’s (Rubin et al., 1985; Rubin & Perse, 1987) short and long version of PSI scale items including those that had been adopted to the PPSR scale, translated them into Bahasa Indonesia using the committee method (Brislin, 1980), and adopted and modified the items that fit our criteria. We also added new items, resulting in a seven-item preliminary version of a PSR-P scale (see Table 1). We then conducted content validation by appointing a panel of experts to judge the quality of the items and calculating the content validity ratio (CVR) for each item as suggested by Lawshe (1975).

Method Participants Twenty Indonesians (9 females, 11 males; Mage = 32.5) were invited to be part of either an expert panel or lay panel to examine the content validity of the initial PSR-P scale. The expert panel consisted of four social psychologists, four political psychologists, three psychometricians, and two political scientists. On the other hand, seven ordinary citizens were included in the lay panel. Their participation was on a strictly voluntary basis. No incentives for participation were provided. This procedure had © 2021 Hogrefe Publishing

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Table 1. The CVR values of the preliminary PSR-P items from the expert and lay people panels Expert panel No.

Item list

Lay panel

CVR

I am very sympathetic to what he or she wants to achieve.

0.846

I find his or her life story to be inspiring.

0.538

0.714

I would love to have dinner with him or her.

0.538

0.428

I am moved by his or her speeches.

0.646

The criticism that is directed at him or her makes me feel angry.

I don’t care about how much political party support he or she has.

538

I think she or he is like an old friend.

0.429

0.538*

Note. CVR = content validity ratio; PSR-R = PSR with political figure. *Discarded.

been approved by the Institutional Review Board of Universitas Sebelas Maret, Indonesia. Procedure Experts received a link to the online validation form of the preliminary PSR-P scale. Following Lawshe’s (1975) content validation method, they were first requested to review the operational definition of the construct, then asked to rate the seven items of the preliminary PSR-P scale into one of three categories: “essential,” “useful, but not essential,” or “not necessary.” The CVR for each item was calculated to determine the level of expert agreement with the formula: CVR = (Ne N/2)/(N/2), where Ne is the number of experts rating “essential,” and N is the total number of experts. The 0.42 of the CVR value was set as the cut-off point following Lawshe (1975). Only items with a CVR value greater than 0.42 were included for further validation processes.

Results The content validation of preliminary PSR-P items produced CVR values that ranged from 0.538 to 1 for the expert panel and 0.429 to 1 for the lay panel. As can be seen in Table 1, only item no. 7 failed to achieve the cutoff point so that it was discarded from the item list. Subsequent construct validations of the PSR-P scale were, therefore, conducted based on the remaining six items (i.e., item nos. 1–6).

Study 2: Factor Structure, Convergent, and Divergent Validity The PSR-P scale was explicitly designed to measure a single latent factor of PSR with a political figure. An exploratory

factor analysis (EFA) using principal axis factoring (PAF) extraction and varimax rotation was performed to examine the factor loadings for the six items from Study 1. Items that had a factor loading lower than 0.40 were excluded from the item list in order to maximize the interpretability of the latent factor (Hair et al., 2006). A confirmatory factor analysis with MLR estimator (50,000 iterations) was used to test the factor structure of the final PSR-P scale (Muthén & Muthén, 2006). Furthermore, we conducted a series of convergent and divergent validation tests by examining the correlations between the final version of the PSR-P and both the PPSR and PSI-P scales. More specifically, we expected PSR-P to show a high correlation with PPSR, given that both were intended to measure the enduring feeling of emotional bonds with a political figure to support the convergence validity of the scale (Hypothesis 1). It is important to note that the PPSR incorporates some aspects of PSI, and thus this correlation should be high, but not too high. Conversely, a lower (moderate) correlation between the PSR-P and PSI-P was expected as evidence of divergent validity (Hypothesis 2), considering that the latter was devised to exclusively measure PSIs (Schramm & Hartmann, 2008).

Method Participants Two hundred and twelve adult participants were recruited in Indonesia through an online snowballing technique (62.9% female; Mage = 25.58, SDage = 7.8). The sample size of the present study was sufficient to achieve at least 80% of power with an α of 0.5 according to Wolf et al. (2013) Monte Carlo power simulation. Participants were required to be 17 years old or above and eligible to participate in the 2019 Indonesian General Election. Their participation in this study was on a voluntary basis. The study has been approved by the Institutional Review Board of Universitas Sebelas Maret, Indonesia.

International Perspectives in Psychology (2021), 10(1), 13–24

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Measures and Procedures Participants who agreed with the statement of informed consent were directed to an online questionnaire consisting of the preliminary PSR-P, PPSR scale, PSI-P scale, and demographic information. In administering the questionnaire, we followed the standard procedure of measuring PSRs (Rubin et al., 1985) by which participants were first asked to nominate their most favored political figure on the national stage (see the Appendix for the list of political figures from Study 2). Subsequently, they were asked to respond to the item list of the preliminary PSR-P (6 items), PPSR (12 items), and PSI-P (13 items) with reference to the nominated figure. Sample items of PPSR included “when (the figure) expresses how he feels about the news, it helps me make up my mind about the media” (1 = disagree completely to 7 = agree completely). In addition, participants were particularly asked to think about the figure during media exposure when responding to the PSIP items (Schramm & Hartmann, 2008). Sample items of PSI-P included “Sometimes I felt like speaking out on (the figure)” (1 = disagree completely to 7 = agree completely). Both PSI and PSI-P scale provided decent internal consistency (0.887 and 0.849, respectively; see Table 3 for descriptive statistics).

were thus excluded from the final PSR-P scale. Next, the retained four items were tested using a confirmatory factor analysis with MLR estimator (50,000 iterations), which showed that the single latent factor model of the final PSRP scale produced very satisfying fit indices, χ2 (2) =1.286, p = .526, RMSEA = .000, CFI = 1, TLI = 1.022, SRMR = .013, with adequate explained variance (43.89%) and good internal consistency, α = .707. In contrast, we found good internal consistency (α = .894), yet insufficient model fit for the PPSR scale,1 χ2 (2) = 20.39, p = .000, RMSEA = .208, CFI = .952, TLI = .856, SRMR = .032, and good internal consistency (α = .849) and good model fit for the PSI-P scale, χ2 (2) =1.087, p = .581, RMSEA = .000, CFI = 1, TLI = 1.012, SRMR = .014 (see Table 3). We then proceeded by testing the convergent and divergent validity of the final PSR-P scale using PPSR and PSI-P as the criterion variables. As displayed in Table 3, PSR-P was highly and positively correlated with PPSR, r = .600, p < .001, confirming Hypothesis 1. We also found a smaller, moderate correlation between PSR-P and PSI-P in accord with Hypothesis 2, r = .451, p < .001. Taken together, these analyses provided initial evidence for the convergent and divergent validity of the PSR-P scale.

Results

Study 3: Measurement Invariance, Discriminant Validity, and Concurrent Validity

Kaiser–Meyer–Olkin (0.741) and Bartlett’s sphericity tests [χ2 (15) = 175.534, p < .001] showed the data were adequate to perform EFA on the six preliminary PSR-P items (Kaiser & Rice, 1974). We ran EFA using PFA with varimax rotation and found that four items loaded highly onto a conceptually coherent factor (Factor 1), while the remaining two items loaded onto a second, less interpretable factor (item nos. 5 and 6; see Table 2). These two items

The goals of Study 3 were threefold: (i) to test the replicability of the factor structure and measurement invariance of the PSR-P with new samples across countries, (ii) to confirm that the PSR-P scale can be distinguished from conceptually irrelevant constructs (discriminant validity),

Table 2. Factor loadings of the preliminary and final items of the PSR-P Step 1: EFA No.

Items

Factor 1

Factor 2

Step 2: CFA

I am very sympathetic to what he or she wants to achieve.

0.684

I find his or her life story to be inspiring.

0.649

—

0.636

I would love to have dinner with him or her.

0.489

—

0.487

I am moved by his or her speeches.

The criticism that is directed at him or her makes me feel angry.

—

0.364*

—

I don’t care about how much political party support he or she has.

—

0.629*

—

0.615

0.213

0.717

0.161

0.634

Note. CVR = content validity ratio; EFA = exploratory factor analysis; PSR-R = PSR with political figure. *Discarded. Selected items in bold.

Tested based on parceled items following Cohen and Holbert (2018).

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M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

Table 3. Descriptive statistics, Cronbach’s α, model fit indices, and Pearson’s correlation coefficients of PSR-P, PPSR, and PSI-P Model fit indices χ

Pearson’s r

RMSEA

CFI

TLI

SRMR

PPSR

PSI-P

1.00

1.022

.013

.600**

.451**

.856

.032

—

.798**

1.012

.014

—

Measures

Mean

PSR-P

5.88

0.765

0.707

1.286

.526

.000

PPSR

5.10

0.901

0.894

20.39†

.000

.208

PSI-P

4.24

0.881

0.849

1.087

.581

.000

†

.952 1.00

1.00

Note. PPSR = political PSR; PSI-P, PSI-process; PSR = parasocial relationship; PSR-P = PSR with political figures. *p < .05; **p < .001. †Based on parceled items.

(iii) to provide evidence of concurrent validity by testing its ability to predict relevant political dispositions in (iv) countries with different political systems. We hypothesized that the PSR-P scale can measure PSRs with political figures equally well across countries, yet has the ability to produce variances that reflect the contextual differences (Hypothesis 3). More specifically, we expected that the factor structure of the PSR-P scale should be replicable, and the meaning ascribed to the items should be equal across sample groups (measurement invariance). On the other hand, it was also expected that the PSR-P scores should be lower in a country with a parliamentary system like New Zealand compared to presidential systems like the United States and Indonesia. Meanwhile, between these two presidential systems, the scores of PSRP scale should be higher in a democratically emerging country like Indonesia compared to its more established counterpart the United States. Moreover, we examined whether PSR-P had discriminant validity in comparison with political ideology, Rightwing Authoritarianism (RWA; Duckitt, 2001), and Benevolent Authority (BA; Liu et al., 2015). The analysis was important to confirm that the measure of PSR with a political figure had little ideological content and was different from authoritarianism in its various incarnations (Garzia, 2011; Lenz, 2013; Schneider, 1994). Weak or nonsignificant correlations between PSR-P and these three criterion variables across countries were expected to demonstrate discriminant validity (Hypothesis 4). Furthermore, just as in traditional interpersonal relationships, PSRs are theorized to motivate one to nurture involvement with the figure of intimacy (Horton & Wohl, 1956). Previous studies in the United States have found that people who maintain a PSR with a political figure are more likely to have a higher interest in politics and show greater elaboration of political information, which subsequently enhances their internal efficacy in political participation (Dunn & Nisbett, 2014). As the criteria for concurrent validity, therefore, we hypothesized that PSR-P should

predict political interest, political elaboration, and political efficacy across cultures (Hypothesis 5).

Method Participants This study initially involved 1,399 adult participants (>17 years old) from Indonesia (N = 305), New Zealand (N= 605), and the United States (N = 489). Participants were recruited online through Nielsen, a global media polling company, on the researchers’ behalf. These data formed a small part of a larger cross-national study, whose sampling methods are reported in Gil de Zúñiga and Liu (2017). Results for the PSR-P have not been previously reported2. Five hundred and two participants (35.9%) did not mention any specific favored political figure and were excluded from the present analysis. This exclusion was taken to ensure that the participants had a target figure in mind when responding to the PSR-P scale, thus reducing measurement errors (Kerlinger, 1986; Rubin & Mchugh, 1987). Our final samples included 897 participants consisting of 206 Indonesians (55.3% female, Mage = 37.74, SDage = 9.55), 366 New Zealanders (54.7% female, Mage = 53.53, SDage = 15.74), and 329 Americans (56% female, Mage = 55.69, SDage = 14), which was sufficient to detect at least 0.8 power with .5 α (Wolf et al., 2013). All participants agreed with informed consent before completing the questionnaire. The current study had been reviewed and approved by Massey University’s Human Ethics Committee. Measures We first asked the participants to nominate their most favored national political figure (see the Appendix for the list of political figures from Study 3). The four items of the PSR-P scale from Study 2 were then used to measure participants’ sense of intimacy with their favored political figure. These items consistently showed good internal

For a full publication listing from the larger dataset, see https://www.dropbox.com/s/oko40j9uzzh1i8j/Digital%20Influence%20World%20Project %20Research%20Output.docx?dl=0.

International Perspectives in Psychology (2021), 10(1), 13–24

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

consistency across sample groups (Indonesia = .879; New Zealand = .846; the United States = .847; see Table 4). The questionnaire also included three variables as the criteria for discriminant validity (i.e., RWA, BA, and political ideology) and three criterion variables for concurrent validity (i.e., political interest, political elaboration, and political efficacy). RWA was measured with a modified four-item RWA scale drawing on items developed by Duckitt (2001). The scale included items such as “Obedience and respect for authority are the most important virtues children should learn” (1 = disagree completely to 7 = agree completely). The internal consistency of this scale was decent for New Zealand (.728) and the United States (.766), and but quite low for Indonesia (.414). BA was measured with a four-item scale developed by Liu et al. (2015) that captured beliefs in the benevolence and moral legitimacy of leaders in central government. This scale included items such as “The leaders in our country set a good example for young people to follow” (1 = disagree completely to 7 = agree completely). This scale provided good internal consistency across sample groups (Indonesia = .780; New Zealand = .849; the United States = .794). Political ideology was measured with three items modified from the European Social Survey tapping into one’s orientations on political, economic, and social issues in terms of liberal-conservatism ideology. The sample items included “On political issues, where would you place yourself on a scale of 0–10, where 10 = strong conservative and 0 = strong liberal.” This scale showed very good internal consistency for each sample group (Indonesia = .917; New Zealand = .938; the United States = .959). Political interest was measured with a single item derived from the World Values Survey asking, “How interested are you in information about what’s going on in politics and public affairs?” (1 = not at all to 7 = a great deal). This scale has been well validated in almost 100 countries, including

Indonesia, New Zealand, and the United States (Inglehart et al., 2014). Political elaboration referred to the extent to which people elaborate on political discussions and conversations they have been engaged in (Eveland, 2004) and was assessed with a four-item scale, which included statements, such as “I often find myself thinking about my conversations with other people about politics and public affairs after the discussion has ended” (1 = disagree completely to 7 = agree completely). This scale showed very good internal consistency across the sample groups (Indonesia = .925; New Zealand = .908; the United States = .914). Internal political efficacy, defined as beliefs about one’s competence to understand, and to participate effectively in politics, was measured with a four-item Internal Political Efficacy Scale drawn from the National Election Survey (Niemi et al., 1991). The scale included items such as “I consider myself well qualified to participate in politics” (1 = disagree completely to 7 = agree completely). This scale provided good internal consistency for New Zealand (.760) and the United States (.761) but was less than acceptable for Indonesia (.400). For the Indonesian sample group, all criterion measures were translated into Bahasa Indonesia using the committee method (Brislin, 1980). Results To test the replicability of the PSR-P factor structure across countries (Hypothesis 3), we performed a confirmatory factor analysis with MLR estimator (50,000 iterations) for individual sample groups (Muthén & Muthén, 2006). As expected, the single latent factor model of PSR-P consistently produced very good model fit for Indonesia (χ2(2) = 2.241, p = .326; RMSEA = .024, CFI = .998, TLI = .995, SRMR = .015), New Zealand (χ2(2) = 6.215, p = .045; RMSEA = .076, CFI = .988, TLI = .963, SRMR = .017), and the United States (χ2(2) = 4.321, p = .115; RMSEA = .060,

Table 4. Descriptive statistics, Cronbach’s α, and the correlation coefficients of the PSR-P and discriminant and concurrent criterion variables Indonesia Variables

Mean

PSR-P

5.36

0.95

.879

(1) RWA

5.37

0.78

.414

(2) BA

3.50

1.28

.780

(3) Political ideology

6.44

2.17

(4) Political elaboration

4.06

(5) Political interest

4.5

(6) Political efficacy

4.02

New Zealand R

United States

Mean

4.49

1.20

.846

.146*

4.51

1.23

.728

0.021

.039

3.92

1.33

.849

.917

.148*

5.11

2.13

.938

1.33

.925

.257**

3.81

1.49

.908

1.4

n. a.

.329**

4.60

1.51

n. a.

0.98

.400

.020

4.10

1.25

.760

Mean

5.12

1.18

.847

R 1

Discriminant validity 4.42

1.35

.766

.098

3.03

1.21

.794

.073

5.54

3.01

.959

.138*

.221**

3.85

1.58

.914

.194**

.353**

5.19

1.52

n. a.

.364**

.221**

4.26

1.34

.761

.248**

.153** 0.02

Concurrent validity:

Note: BA = benevolent authority; PSR-P = PSR with political figures; RWA = right-wing authoritarianism. *p < .05, **p < .01.

International Perspectives in Psychology (2021), 10(1), 13–24

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

CFI = .992, TLI = .976, SRMR = .016). Next, we performed invariance measurement tests to assess whether the factor structure of the PSR-P scale and the meaning of the items were equal across sample groups. The measurement invariance was examined using the Satorra-Bentler χ2 (SB χ2) difference test with scaling correction (Satorra & Bentler, 2011). Our analysis revealed that the configural model (χ2 (6)= 11.525, p = .073; RMSEA = .055, CFI = .992, TLI = .977, SRMR = .016), metric model (χ2 (12)= 18.399, p = .104; RMSEA = .042, CFI = .991, TLI = .987, SRMR = .058), and scalar model of the PSR-P scale (χ2(18) = 33.833, p = .013; RMSEA = .054, CFI = .978, TLI = .978, SRMR = .076) produced good model fit. More importantly, the model yielded full metric (SB χ2 (Δdf = 6) = 5.954, p = .428) and scalar invariance (SB χ2 (Δdf = 6) = 16.548, p = .011) across sample groups. In addition to this scalar invariance, further analysis with ANOVA showed that the scores produced by the PSRP scale significantly varied across countries, F(2) = 45.79, p < .001, where New Zealand showed significantly lower mean score compared to the United States (ΔM = 0.625, SE = 0.087, 95% CI [ 0.795 to 0.454], p < .001) and Indonesia (ΔM = 0.865, SE = 0.099, 95% CI [ 1.060 to 0.670], p < .001). On the other hand, the mean score for the United States was also significantly lower compared to Indonesia (ΔM = 0.240, SE = 0.102, 95% CI [ 0.440 to 0.041], p = .018). In summary, these results supported Hypothesis 3 in that the factor structure of PSR-P was replicable, and the meaning ascribed to the items were invariant across countries, yet the mean scores the scale produced varied predictably according to contextual differences in the political culture of the three countries. In terms of discriminant validity, we found nonsignificant correlations between PSR-P and RWA for both New Zealand (r = .021, p > .05) and the US sample groups (r = .098, p > .05). This correlation, however, was significant yet small for the Indonesian samples (r = .148, p < .05).3 In addition, we found nonsignificant correlations of PSR-P and BA for the Indonesian (r = .039, p > .05) and the US sample groups (r = .073, p > .05), and a small yet significant correlation for the New Zealand samples (r = .153, p < .01). These findings confirmed that PSR-P was not identical with authoritarianism. Moreover, the relationships between PSR-P and political ideology were mixed yet consistently weak across sample groups. The correlation was significant and positive for the Indonesians (r = .148, p < .05), nonsignificant for the New Zealanders (r = .02, p > .05), and significant and

3 4

negative for the US participants (r = .138, p < .05). In summary, our analyses provided sufficient evidence for the discriminant validity of PSR-P scale in comparison with RWA, BA, and political ideology across countries, supporting Hypothesis 4 (see Table 4). As for concurrent validity, we found significant and consistent correlations between PSR-P and two criterion variables across countries, including political elaboration (Indonesia, r = .257, p < .01; New Zealand, r = .221, p < .01; the United States, r = .194, p < .01), political interest (Indonesia, r = .334, p < .01; New Zealand, r = .345, p < .01; the United States, r = .382, p < .01). Meanwhile, significant and positive correlations between PSR-P and internal political efficacy were found for New Zealand (r = .220, p < .01) and the United States (r = .262, p < .01), but not for Indonesia (r = .242, p < .01)4. Again, these results supported Hypothesis 5 in that PSR-P was able to produce adequate concurrent validity across sample groups.

General Discussion Our aim in this study was to develop a scale to measure ordinary people’s feeling of distant intimacy (or, PSR) with political figures. We found that the four items of the PSR-P developed had sufficient psychometric properties to measure a PSR-P as a distinct psychological construct. PSR-P exhibited convergent validity against the PPSR scale, which was similarly intended to measure PSRs with political figures. Moreover, PSR-P demonstrated divergent validity by producing a moderate correlation with the PSIP scale that was primarily designed to measure PSI. In contrast, the PPSR scale showed a high correlation with PSI-P and produced an insufficient model fit, implying that there might be some conceptual problems related to the construct validity of the scale. Finally, the PSR-P scale also provided evidence of factor replicability, scalar invariance, discriminant validity, and concurrent validity based on samples from countries that are varied in terms of the type of political system and the level of democratic maturity (i.e., Indonesia, New Zealand, and the United States). The construct of PSR as measured by PSR-P implies that interpersonal processes are involved in the relationship between voters and candidates. Instead of relying solely on the candidates’ ideology and authority, some individuals appeared to utilize interpersonal frameworks in the understanding of and developing symbolic closeness with

Please note that the RWA scale showed poor internal consistency for the Indonesian sample. Please note that the Internal Political Efficacy scale showed low internal consistency for the Indonesian sample.

International Perspectives in Psychology (2021), 10(1), 13–24

particular political figures. As shown in the current study, such interpersonal-based political attachments exhibited weak and inconsistent correlations with political ideology, RWA, and BA across countries. The PSR model suggests that individuals who form PSRs with a distant figure like a political candidate are more likely to see the figure as though she or he was their acquaintance, but with higher status (i.e., an asymmetrical relationship; Rubin & Mchugh, 1987). For these individuals (approximately 64% of nationally representative samples from three countries), the nominated political figure is theorized to serve as a source of comfort, enjoyment, and a role model (Giles, 2002). The PSR-P scale allows researchers to empirically investigate further such propositions across countries with a psychometrically and cross-culturally robust measure of PSR. Furthermore, central to parasocial theory is the idea that one is motivated to nurture PSRs just like in real interpersonal relationships. The theory posits that individuals who are in a PSR with a particular figure are more likely to find out more about the given figure’s private and social life (Horton & Wohl, 1956) and learn vicariously from the figure’s experiences (Dunn & Nisbett, 2014). Indicative of such tendencies, our analysis revealed that PSRs with political figures had significant and positive associations with a higher interest in politics, greater elaboration of political information, and higher internal political efficacy across sample groups. These results were consistent with previous findings from Dunn and Nisbett’s (2004) study and also showed that such patterns could be found across political and cultural settings. Finally, our PSR-P scale is brief yet sufficiently powerful to assess people’s PSRs with political figures, the central psychological process underlying the personalization of politics, across political contexts. We have provided evidence that the PSR-P scale has the ability to produce psychometrically equivalent scores across countries and at the same time shows enough sensitivity to capture anticipated mean differences according to contextual factors as the type of political system and level of democratic maturity. In line with previous studies of the personalization of politics at macro levels (Garzia, 2011; Rahat & Kenig, 2018), we found that on average, people in a parliamentary system and established democracy like New Zealand showed significantly lower PSRs with political figures compared to their counterparts in another established democracy with a presidential system like the United States. On the other hand, people in a presidential system yet democratically emerging like Indonesia showed higher PSRs with political figures than people in the more established presidential system of the Unite States. The brevity of our PSR-P scale allows researchers to investigate the phenomena of PSRs with political figures in other political contexts efficiently and with sensitivity. International Perspectives in Psychology (2021), 10(1), 13–24

M. A. Hakim & J. H. Liu, Parasocial Relationship With Political Figures

In conclusion, the PSR-P scale provided robust psychometric properties to measure PSRs with political figures. Hence, the scale can be utilized to advance the application of parasocial theory as an explanatory framework of the psychological process underlying the personalization of politics across countries. One of the most important policy implications of our findings related to its potential utility to monitor the trend of political personalization in a particular country (see Hakim & Choi, 2020 as an example in New Zealand). The development of PSRs with political figures among ordinary citizens may decrease the quality of democracy over times, as it inhibits the citizens’ ability to evaluate the political figures critically. Our PSR-P scale can be used to assess and monitor these personalization trends longitudinally so that the negative impacts of such trends on democracy might be mitigated.

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Acknowledgments The first author acknowledges the support from the Doctoral Scholarship Program of Lembaga Pengelola Dana Pendidikan (The Indonesian Endowment Fund for Education). Open Data All data and code used in the present study are available at Harvard Dataverse: https://doi.org/10.7910/DVN/F3KS7M.

Appendix

ORCID Moh Abdul Hakim  https://orcid.org/0000-0002-2606-143X James H. Liu  https://orcid.org/0000-0001-9520-5727 Moh Abdul Hakim Department of Psychology, Faculty of Medicine Universitas Sebelas Maret, Indonesia Jl. Ir Sutami No. 36 A, Surakarta Indonesia, 57126 m.a.hakim@staff.uns.ac.id

Table A1. List of the most favored political figures from Study 2 and Study 3 Study 2

Study 3

Indonesia Political figures

Indonesia Freq

Joko Widodo

Basuki Tjahaja Purnama Ridwan Kamil

Political figures

New Zealand Freq

Political figures John Key

United States Freq 140

Political figures Donald Trump

Freq

Basuki Tjahaja Purnama

Joko Widodo

Winston Peters

Bernie Sanders

Ridwan Kamil

Andrew Little

Hillary Clinton

Anies Baswedan

Prabowo Subianto

Jacinda Ardern

Ted Cruz

Bacharuddin Jusuf Habibie

Soeharto

Meteria Turei

Barack Obama

Mahfud MD

Bacharuddin Jusuf Habibie

Paula Bennet

John Kasich

Prabowo Subianto

Susilo Bambang Yudhoyono

Bill English

Elizabeth Warren

Susi Pudjiastuti

Tri Rismaharini

David Seymore

Ben Carson

Amien Rais

Mahfud MD

Peter Dunne

Marco Rubio

Sri Mulyani

Abdurrahman Wahid

Phil Goff

Paul Ryan

Anis Matta

Hidayat Nur Wahid

Judith Collins

Paul Ryan

Tri Rismaharini

Surya Paloh

Annette King

Bill Clinton

Fahri Hamzah

Ahmad Heriyawan

Grant Robertson

Carly Fiorina

Ganjar Pranowo

Amien Rais

James Shaw

Joe Biden

Sandiaga Uno

Ki Hajar Dewantara

Amy Adams

Condoleeza Rice

Susilo Bambang Yudhoyono

Megawati Sukarno Putri

David Shearer

Jeb Bush

Agus Harimurti Yudhoyono

Moh Hatta

Jan Logie

Joe Manchin

Airlangga Hartarto

Soekarno

Kelvin Davis

John McCain

Akbar Faisal

Susi Pujiastuti

Nathan Guy

Amy Klobuchar

Dinopatti Djalal

Ganjar Pranowo

Maggie Barry

Chris Christie

Eko Sriyanto Galgendu

Retno Marsudi

Steven Joyce

Collin Peterson

Emil Dardak

Rohut Sitompul

Stuart Nash

Corey Booker

Hatta Rajasa

Sandiaga Uno

Bob Parker

Gary Johnson

Jusuf Kalla

Sri Sultan Hamengkubuwono IX

Colin Craig

J.F. Kennedy

Khofifah Indar Parawansa

David Clark

Jeff Flake

Retno Marsudi

Helen Clarke

Kamala Harris

Rizal Ramli

Hone Harawera

Michael Bloomberg

Rocky Gerung

Iain Lees-Galloway

Mike Amyx

Salim Segaf Al-Jufri

Julian Crawford

Mike Coffman

Soekarno

Megan Woods

Steve Scalise

Tuan Guru Bajang

Tulsi Gabbard

International Perspectives in Psychology (2021), 10(1), 13–24

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Article

Pakistani Immigrants’ Nuanced Beliefs About Shame and Its Regulation Fanie Collardeau1, Muhammad Usama Bin Aftab1, Tahira Jibeen2, and Erica Woodin1 Department of Psychology, University of Victoria, Victoria, BC, Canada

Advance Health, Toronto, ON, Canada

Abstract. The present study explored beliefs about shame and coping strategies of Pakistani immigrants to Canada, without imposing Western definitions or theories. Semistructured interviews were conducted with 18 adult Pakistani immigrants to Canada who immigrated within the last 8 years. Grounded theory was used to uncover and illuminate how shame could act as a signal for wrongdoing or emerge as a result of social control and social hierarchies, while in both instances being shaped by and informing complex relational and social contexts. Participants accessed a wide range of positive and negative coping behaviors and prioritized positive coping strategies which included close others and focused on self-improvement. The findings highlight the need for researchers to expand current definitions of shame to render them more inclusive of non-Western worldviews and to honor the diversity in metacognitions or beliefs about shame present in different cultural groups. Future research may also benefit from exploring how shame may be felt as a response to power differentials, and how this may impact individuals’ experiences of immigration. It is important for practitioners working with Pakistani immigrants to Canada to honor clients’ nuanced and complex cultural and religious knowledge about shame, as Pakistani immigrants’ beliefs about shame and their proactive stance toward the regulation of this emotion are likely to be protective. We also encourage therapists to be open to discussing sources of shame (e.g., personal vs. imposed by others) and systemic, structural inequalities which may be important in explaining individuals’ emotional experience. Keywords: shame, Pakistani immigrants to Canada, metacognitions, emotion regulation, qualitative Impact and Implications. The present study suggests that Pakistani immigrants have nuanced beliefs about shame and differentiate between instances when shame acts as a signal for wrongdoing and when it emerges as a result of social control and social hierarchies. They are then able to access a wide range of emotion-regulation strategies. Research on shame needs to become more inclusive of non-Western worldviews and definitions.

As of 2016, Pakistani-born individuals represent one of the top 10 largest groups of foreign-born individuals in Canada. Between 2011 and 2016, Pakistan was the fifth largest contributor (even surpassing the United States) of immigrants to Canada and accounted for just over 40,000 immigrants in these 5 years alone (Statistics Canada, 2017). Furthermore, 9.3% of South Asians, the largest visible minority group in Canada, reported being of Pakistani heritage in 2011 (Statistics Canada, 2011). Pakistani immigrants to Canada are faced with multiple challenges, including loss of status and social support, significant economic hardships, culture shock, and discrimination (Jibeen & Khalid, 2010a, 2010b; Khan & Watson, 2005). They frequently live in social contexts where multiple aspects of their identities (i.e., nationality and religion) are devalued and may be openly rejected by the majority (Jamil, 2014; Rousseau & Jamil, 2008). This puts them at higher risk of experiencing feelings of inferiority (Jamil, © 2021 Hogrefe Publishing

2014; Rousseau & Jamil, 2008) and stigma-related shame. Indeed, shame can occur as a reaction to frequent experiences of social rejection or stigma against one’s ethnicity (Schmader et al., 2015; Schmader & Lickel, 2006) or religion (Rodriguez Mosquera, 2018). Thus, a more culturally sensitive and in-depth understanding of how Pakistani immigrants to Canada understand and regulate experiences of shame – whether those are related to experiences of discrimination or not – may allow us to identify protective factors present for the Pakistani immigrant community and additional regulation strategies. While the challenges associated with Pakistanis immigrating to Western countries have been documented (Jibeen & Khalid, 2010b; Khan & Watson, 2005), little is known about how Pakistani immigrants residing in Canada view and understand emotional experiences such as shame. Beliefs about emotional experiences, including shame, emerge within individuals’ social and cultural International Perspectives in Psychology (2021), 10(1), 25–38 https://doi.org/10.1027/2157-3891/a000004

contexts (Bastian, 2013). Socially and culturally situated discourses about emotional experiences may influence beliefs or metacognitions about emotions held by members of a cultural group (Bastian, 2013). Metacognitions, along with metaemotions, refer to individuals’ knowledge and beliefs about emotions as well as secondary emotional reactions to emotions (Gottman et al., 1996; Norman & Furnes, 2016). Individuals might view emotions generally or specific emotions, such as shame, positively (e.g., emotions as helpful signals, confidence in own capacity to regulate emotions; Beer & Moneta, 2012) or negatively (e.g., emotions are unhelpful, invalid; Manser et al., 2012). Those metacognitions may include beliefs about the emotion’s helpfulness or role, as well as beliefs in one’s capacity to tolerate or regulate the emotion. In Western populations, preliminary evidence suggests that beliefs about emotions may be predictive of emotion-regulation strategies (Lane et al., 2011). For example, athletes holding beliefs about the beneficial impact of anxiety and anger on performance not only reported higher anger and/or anxiety intensity before a performance but also used strategies to increase those emotions (Lane et al., 2011). Thus, shared sociocultural beliefs about shame may have important implications for individuals’ strategies to regulate this emotion. In Pakistan, sharam is one of the possible words used to refer to shame. However, anthropological research suggests that sharam can take a multiplicity of meanings, including shame, concealment, modesty, or embodied self-control, depending on the context (Alvi, 2013). Sharam is at least linguistically directly embedded within notions of morality and appropriate behaviors. Additionally, in Islam, which is the main religion in Pakistan with more than 90% of the population being either Sunni (majority) or Shi’a Muslims (Naeem et al., 2015), the self is perceived as being inherently good, and faith helps to reconnect with one’s pure or better self (Qulsoom, 2005). Remorse and shame act as signals to understand one’s mistakes and repent and ultimately improve the self (Qulsoom, 2005). Acting in accordance with the Quran is seen as an individually desirable goal and may provide individuals with an increase in their social status independent of their wealth (Maqsood, 2017). In so far as one’s morality partially determines social status, it is possible that culturally appropriate displays of shame and repentance may also work as indicators of one’s respect for cultural norms and morality and hence as indicators of social standing. The acceptability of specific behaviors is influenced by both prescriptive (“should,” e.g., praying five times a day) and proscriptive (“should not,” e.g., not eating pork) rules within Islam. The acceptability of specific behaviors is further informed by gendered norms, age (with elders having a higher social status), family traditions, and conflicting perspectives on religious guidelines both in International Perspectives in Psychology (2021), 10(1), 25–38

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

Pakistan and in the Muslim diaspora (e.g., Bush et al., 2003; Maqsood, 2017; Stodolska & Livengood, 2006). It is likely that the experience of shame is also influenced by individuals’ location within the larger Pakistani cultural norms. Additionally, Pakistani immigrants to Canada are in the unique position of having to reconcile Pakistani conceptualization of shame and Canadian beliefs about shame. Indeed, social constructionist researchers have provided preliminary evidence that, due to ongoing interpersonal interactions with members of the majority culture, immigrants’ emotional reactions to specific situations may become, over time, more concordant with the emotions experienced by members of the new culture (De Leersnyder et al., 2011; Mirdal, 2006). It is thus possible that, over time, Pakistani immigrants’ beliefs about shame change due to their immigration experience and that they may begin to incorporate some Canadian beliefs. To our knowledge, no study has explored the beliefs about shame held by Pakistanis or Pakistani immigrants, without imposing the most frequently used Western conceptualization of shame that views the emotion as solely painful and maladaptive (Tangney, 1996; Tangney et al., 2007). Qualitative approaches can allow researchers to explore individuals’ metacognitions or beliefs about shame without imposing Western norms and in a culturally sensitive way. They may lead to a broader or more nuanced understanding of experiences of shame within specific cultural and social contexts. For instance, in a recent ethnographic study, Subandi and Good (2018) explored beliefs about shame held by families of Javanese individuals who experienced their first psychotic illness. Their work recognizes the complexity of Javanese conceptualizations of shame, and its role as a potential marker for seemingly unrelated processes (e.g., recovery from a psychotic illness). Participants perceived shame to be an important marker of good mental health and recovery from psychotic illness. The expression and experience of shame in culturally appropriate ways signaled individuals’ awareness and respect of social norm, while mental illness interfered with individuals’ capacity to act appropriately and to demonstrate their morality and respect for norms (Subandi & Good, 2018). These findings paint a rich picture of shame that is qualitatively different from majority of Western conceptualizations.

The Current Study The current study uses qualitative interviews and grounded theory to explore how Pakistani immigrants to Canada understand and make sense of their experiences of shame, without imposing a Western framework or definition of the © 2021 Hogrefe Publishing

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

emotion. Thus, our research aims to address the following questions: a. What is the purpose of shame, if any, according to Pakistani immigrants to Canada? b. How do they make sense of and regulate this emotional experience? c. Do they feel their understanding of shame or coping with shame was influenced by their immigration to Canada?

Methods

19th birthday, but within the last 8 years (Table 1). Seven women and 11 men across Canada participated. The interviews were conducted in English (14 participants, 77.8%), Urdu (three participants, 16.7%) with the help of a translator, or in both languages (one participant, 5.6%) in the presence of a translator. More than half (55.6%, 10 participants) of the participants completed the interview over the phone. Seven participants (38.9%) completed the interview by e-mail. Finally, one participant started the interview by e-mail and decided to finish over the phone. One participant, who elected to respond over e-mail, stopped responding partway through the interview in the context of COVID-19.

Participants

Researchers

To be eligible, participants had to be born and raised in Pakistan and to have immigrated to Canada after their

As the first author, I (Fanie Collardeau) was the principal investigator for the study, which was completed as a part of

Table 1. Demographic information Demographic information Age

M, SD, and percentages M = 35.50, SD = 8.74 (range = 24.5–61 years old)

Age at immigration

M = 31.89, SD = 7.48 (range = 22–53 years old)

Time since immigration

Less than 1 year: 16.7% (3) 1–2 years: 27.8% (5) 3–4 years: 16.7% (3) 4–6 years: 16.7% (3) 7–8 years: 22.2% (4)

Number of migrations

Canada only: 83.3% (15) Canada + another country: 11.1% (2) Canada + 2 other countries: 5.6% (1)

Current province (Canada)

Alberta: 22.2% (4) British Columbia: 22.2% (4) Ontario: 50.0% (9) Saskatchewan: 5.6 (1)

Province of origin (Pakistan)

Sindh: 55.6% (10) Punjab: 44.4% (8)

Cultural background

Punjabi: 50.0% (9) Mahajir: 38.9% (7) Memon: 5.6% (1) Urdu speaking: 5.6% (1)

Religion

Atheist: 11.1% (2) Muslim – not further specified: 38.9% (7) Sunni Muslim: 33.3% (6) Hanafi Sunni Muslim: 11.1% (2) Shia Muslim: 5.6% (1)

Occupation

Full-time employment: 72.2% (13) Part-time employment: 5.6% (1) Student + part-time job: 5.6% (1) Stay-at-home parent: 11.1% (2) Retired: 5.6% (1)

Language currently spoken at home

Urdu: 55.6% (10) Punjabi: 5.6% (1) Urdu and Punjabi: 5.6% (1) Urdu and English: 33.3% (6)

Note. Please note that we did not collect information on immigration status or socioeconomic status. M = mean; SD = standard deviation.

International Perspectives in Psychology (2021), 10(1), 25–38

my PhD dissertation in Clinical Psychology at the University of Victoria. My undergraduate and MA theses provided me with many opportunities to hone my training in qualitative methodologies, and more specifically grounded theory. My work as a researcher is also located within my personal experience. I grew up in France, in a family of Spanish origins. I moved to Canada in 2013 and now have ties to the immigrant Pakistani community through marriage and friendships. Furthermore, I am a white, cisgender woman of Muslim faith. My formal education and background put me in multiple positions of power. I am both a Western outsider and a partial insider due to close personal ties with the community. Rapport building with participants was approached keeping my multiple identities and privileges in mind (described below). Some participants’ narratives suggested they considered me as a partial insider (e.g., calling me sister-inlaw, assuming I would know certain traditions), while others seemed to consider me as more of an outsider (e.g., defining simple Urdu words). I received direct and ongoing supervision, direction and support from my supervisor, supervisory committee, and team members, including the study’s consultant, Dr. Tahira Jibeen. Muhammad Usama Bin Aftab was a translator and second coder for the study. He received training on qualitative interviewing and data analysis from the first author. He is fluent in Urdu and English and is a Pakistani immigrant to Canada. He was involved at all stages of the study. Dr. Tahira Jibeen was a consultant for this study. She previously conducted research with Pakistani immigrants to Canada and has expertise in quantitative and qualitative methods. Dr. Erica Woodin is the PhD supervisor of Fanie Collardeau and has expertise in metaemotion philosophies and qualitative interviewing methodologies.

Procedure The Institutional Review Board at the University of Victoria (British Columbia, Canada) approved the study. Recruitment and Interview Participants were recruited through word of mouth, online forums, and Facebook. Participants were invited to share the study’s poster with their networks. Participants completed a short online demographics questionnaire to sign up for the study. Participant consent was obtained as part of the online survey prior to interviews. Eligible participants completed a qualitative and open-ended interview by e-mail or telephone. E-mail interviews were completed over the course of 3 weeks to 3 months. Telephone International Perspectives in Psychology (2021), 10(1), 25–38

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

interviews were 45 minutes to 1 hour in duration and were audiotaped and then transcribed by the first author. The interview explored participants’ beliefs about the role and regulation of shame and how their beliefs may have changed over time and after immigrating to Canada, as well as common beliefs about shame in Pakistan. Any identifying information was deleted to protect participants’ anonymity. Participants were given the choice to participate through telephone or e-mail to increase ease of participation. To build rapport with participants, the interviewer (first author) took some time to informally chat with participants before the telephone interview started, responded to some personal questions (e.g., question about her faith or about whether she had visited Pakistan), and, when appropriate, demonstrated her basic knowledge of Urdu (e.g., helping participants translate Urdu words she knew during interviews in English). E-mail interviews are a relatively new medium for qualitative interviews with hard to reach or understudied populations (Neville et al., 2016). Multiple studies have shown that data collected in e-mail interviews are of equivalent quality to data collected in face-to-face or telephone interviews (e.g., Coderre et al., 2004; McCoyd & Kerson, 2006). Key concerns about e-mail interviews mainly focus on the risk of data fraud (Hamilton & Bowers, 2006), the lack of nonverbal cues (Cook, 2012; McCoyd & Kerson, 2006), and privacy/anonymity (James & Busher, 2006). Yet, e-mail interviews also offer multiple advantages including longer periods of reflection for both the researcher and the participant, which can increase the richness and quality of the data collected (e.g., Cook, 2012; McCoyd & Kerson, 2006; Neville et al., 2016), and lead to higher satisfaction and control reported by participants (e.g., Egan et al., 2006; Neville et al., 2016) and higher disclosure of sensitive information (e.g., Cook, 2012; Egan et al., 2006). To include immigrants who might be less acculturated, participants could complete the interview in English or Urdu. After all interviews were completed and analyzed, participants were sent the preliminary theory derived from the study and invited to provide feedback, which further informed the theory. Ensuring Quality and Data Analyses The interviews were analyzed using constructivist grounded theory (Charmaz, 2014, 2017). Grounded theory allows for systematic data collection and analysis, and is well suited to topics for which previous research is limited (Charmaz, 2014; Chenitz & Swanson, 1986). Constructivist grounded theory recognizes the co-construction of narratives by participants and researchers. It aims to illuminate meanings held by individuals through dialogs and analyses. In grounded theory, data collection and analyses occur concurrently. The co-occurrence of data collection and © 2021 Hogrefe Publishing

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

analyses allows for a responsive approach to data collection, in which interview questions are added to clarify emerging themes. It also allows for theoretical sampling, whereby recruitment in the current study targeted increased participation by women once a gendered component of shame emerged in the initial analyses. Initially, interviews were coded line-by-line, meaning that codes were generated for each line of text. Those initial codes were grouped to form preliminary conceptual categories and themes. The relationships between the emerging categories and their integration into a grounded theory emerged through axial coding and selective coding strategies (Charmaz, 2014). Due to the simultaneous nature of data collection and analyses, two questions were added to the interview to clarify emerging categories. New data were compared with the existing concepts and emerging theory (Charmaz, 2014). Data analysis began after the first interview in August 2019 and continued until July 2020. Multiple standard steps were taken to improve the quality, credibility, trustworthiness, and rigor of this qualitative study. First, the first author engaged in an ongoing reflexive process to explore her beliefs, biases, and personal experiences and documented her reflections (Charmaz & Thornberg, 2020; Finlay, 2002; Williams & Morrow, 2009). She was careful not to presume she understood participants’ experiences and strove to stay close to the data. Second, two research assistants, one of whom is a Pakistani immigrant to Canada, were invited to each code 3 interview transcripts using the first author’s codebook. All research assistants were encouraged to keep a reflexive journal during their involvement in the study. Differences in coding and instances where research assistants identified missing codes were discussed. When needed, the first author and research assistants engaged in additional line-by-line coding to incorporate emerging insights into the theory. Third, participants were sent a narrative summary of the theory and invited to provide feedback on whether the theory resonated and provided a useful framework (Madill et al., 2000). Finally, memos were kept at all stages of the research (Birks et al., 2008; Charmaz & Thornberg, 2020). Those measures allowed us to reflect more deeply on the meanings ascribed to the interviews and to enhance the credibility and trustworthiness of the study.

Results Participants identified 20 words, including sharam, zillat, haya, and baizati, that they could use to describe feelings of shame. Their descriptions of the emotion included © 2021 Hogrefe Publishing

physical sensations (e.g., “sinking feeling”), urges (e.g., “strong and immediate impulse to withdraw”), and thoughts (e.g., “it made me feel like I was just not good enough”), which have been frequently associated with shame within the Western literature. While a few participants endorsed the shame-guilt distinction common in the Western literature (Tangney, 1996; Tangney et al., 2007), most saw shame and guilt as occurring on a continuum ranging, at its most, from embarrassment to humiliation. The main themes and coping strategies are presented in Figure 1. Shame was thought about and understood within a rich, culturally embedded system of meaning-making. Specifically, participants articulated how shame could act as a signal for wrongdoing or emerge as a result of social control, while in both instances being shaped by and informing complex relational and social contexts. Most participants balanced a belief in the positive individual and social benefits of shame (endorsed by all) with a critique of problematic socially endorsed uses of shame within the Pakistani society (endorsed by most). Compared to men, women tended to be more critical of how shame could be used to prompt obedience and reported more instances where they were shamed. Furthermore, participants’ beliefs about shame allowed them to access a wide range of coping behaviors when feeling ashamed and led most participants to prioritize coping strategies which included others or focused on self-improvement. Most positively perceived coping strategies were viewed to lead to selfchange and self-improvement; thus, both reinforcing and illustrating how shame could act as a beneficial signal of wrongdoing. Some participants reflected on the benefits of taking an Islamic approach to understanding and dealing with shame.

Shame as a Signal for Wrongdoing Most participants endorsed the view that shame’s main purpose is to differentiate right from wrong. Shame occurs within specific cultural and religious value systems and allows individuals to recognize the moral implications of their behaviors. As one participant stated, “I feel sharam is a blessed feeling, it tells you [the] person is afraid to do wrong things which are prohibited [by religion] and encourage him, her to talk about [it].” Thus, shame signals that a specific action will bring feelings of shame (i.e., is not acceptable for the person or society) or if the action was already taken that this action is undesirable and has negative consequences. Some participants defined wrongdoings as an action that goes against group norms and keeps the individual within the culturally defined boundaries or limits of one’s group. One participant even ascribed to an understanding of shame International Perspectives in Psychology (2021), 10(1), 25–38

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

Figure 1. The theoretical model of Pakistani immigrants to Canada’s conceptualization and regulation of shame.

purely motivated by cultural norms: “[in Canada] So, I mean, and what I found that in men’s room they, it is pretty normal to change one’s clothes in front of tens or hundreds of people, you know? So it is kind of a do-as-the-Romansdo kind of feeling thing.” The salience of cultural norms explained changes in sources of shame experienced by some participants (e.g., experiencing shame while wearing traditional clothes outside, but no longer feeling ashamed in the men’s room at the gym) postimmigration. On the other hand, others implied the superiority of one’s own moral compass over social norms and saw shame as an internal and personal signal for undesirable behaviors. For example, a participant explained, “As a person develops self-awareness and begins to consider their emotional responses more mindfully, the assumption is that they would be able to separate socially indoctrinated shame from a more critically considered sense of right and wrong. In that case, shame can indicate to a person that their behavior conflicts with their moral compass. If nothing else, it exposes our own biases about ‘good behaviour’ and ‘bad behaviour’ to us.” For a number of participants, religious rulings were not perceived as external sources defining moral behavior. Instead, they International Perspectives in Psychology (2021), 10(1), 25–38

viewed religion and religious teaching as forming part of their personal, introspective sense of morality. For women, religious rulings were at times framed in opposition to unwanted cultural norms and used to justify behaviors not approved by the collective but allowed by Islam.

Relational and Contextual Shame Most participants reported that their current understanding of shame had been significantly shaped by their parents. Shame was described as occurring within different social contexts and competing norms (e.g., religion might allow one thing that culture does not, and family and friends may have different norms) in the Pakistani context, which meant both shame and wrongdoings are highly contextualized events. The following excerpt highlights multiple elements of the theme: “The shame is one emotion that. . . that you learn from people around you and your society, it doesn’t, it doesn’t, it doesn’t come with you from your mother’s womb, right? You just learn it. Like cry is kind of, it is a natural thing for people to cry. But shame I think it has to do a lot with people you live with, and society © 2021 Hogrefe Publishing

F. Collardeau et al., Pakistani Immigrants’ Beliefs About Shame

and expectations from people [. . .] I think in Canada people, they think. . . The meaning for shame is different than in Pakistan. Pakistan, everything, you are connected with everybody, and if you do anything you will bring shame to your family, to the whole community and you have to. . . you have to present best of yourself in Pakistan. There are a lot of expectations from you. People are expecting a lot from you. In Canada, people, they. . . if it doesn’t affect them directly, they don’t care.” Thus, shame is not only shaped over time by the social context, but it may also be a shared experience among a family or community, based on the behavior of one of the group’s members. This shared experience of shame is often accompanied by a shared sense of responsibility, which may lead other members of the group to act to repair the effects of the individual’s shameful behavior. Participants had diverging opinions about the helpfulness of others’ actions, in part due to the variety of responses from fellow family or group members. While others could be supportive and problem-solve ways to positively resolve the situation, they could also fail to protect the individual from unfounded accusations or could even react aggressively. Some participants, in addition, commented on the ways in which hierarchies within families could alter processes of reconciliation. For example, a participant explained apologizing to his elder after the latter had acted negatively toward him in public and made sense of the situation in the following way: “with social sharam [note: as opposed to sharam based on one’s personal compass], its mostly societal pressure that would force reconciliation, based on the idea that family has a certain claim over the person and said claim comes with a pass for transgression which are chalked up to ‘they only say/do this because they care’ attitude.” Nevertheless, all participants underlined the importance of having supportive others one could turn to when experiencing shame. Supportive others could be family members, friends, or God. Supportive others provided advice and trusted in the shamed person’s ability to successfully overcome the situation they are in (if appropriate shame) or provided reassurance and explained the person is not at fault (if inappropriate shame). If the person had done something wrong, they reported others, including parents, may engage in “a kind of consoling: If you have done this thing wrong today, next time you have to do this way, or don’t do it, or improve yourself this way.” Participants also reported wishing to be this supportive person: “If the person is my age, then I can be a little more friendly about it and share my own experiences as well, to make the person comfortable. If there is a kid then, I will treat him like a kid and tell him to be ok, it happens, next time you can handle this situation like this. you could do this next time etc.” When mentioned, God was a forgiving, © 2021 Hogrefe Publishing

merciful other, whose mercy was certain if one expressed true repentance for a wrongdoing: “And even if that shame is justified, in our religion, as long as you feel bad about it afterwards, and you say that you will not do it again – although of course you may still do it again, you never know – so even then as long. . . we are told you see by Allah as long as you repent to him for forgiveness, if you are sincere in that then you are forgiven.” Thus, family is viewed as an integral medium in which the experience of shame occurs. This relational aspect of shame can then be extended to the importance of the larger group (society) acting as an audience (imagined or very much real when others inform family members of one’s own undesirable actions). As the participant cited above emphasized, within the Pakistani context: “everything, you are connected with everybody, and if you do anything you will bring shame to your family, to the whole community and you have to. . . you have to present best of yourself in Pakistan. There are a lot of expectations from you. People are expecting a lot from you. In Canada, people, they. . . if it doesn’t affect them directly, they don’t care.” The lesser relational nature of shame in Canada was mentioned by a few participants to explain the decreased frequency of feelings of shame related to others (e.g., feeling shame due to someone else’s action and causing shame to others) since their immigration.

Problematic Shame and Social Control Simultaneous with reports of supportive and well-meaning others, a number of participants felt very negatively about others enforcing social and cultural norms. They reported that feelings of shame can be initiated through exposing and calling out someone else’s actual or imagined wrongdoing, or by people’s use of their superior social standing. Shaming thus is used as a way to maintain or force adherence to appropriate behaviors: “Shame is a means of social control in Pakistani society. The emotion has always seemed to exist in conjunction with social norms but in Pakistan it has been coopted to the point where shame has become a quasi-social institution rather than an emotion. It is not a feeling anymore, it is an experience. An experience that can be brought onto others and can be used as a threat to compel certain actions.” Participants also understood shame to occur within social hierarchies, such as socioeconomic status, gender, skin color, or education, whereby “if someone is superior, they will try to burdenize the inferiors, so that, [they] make them feel shame.” For many women and one atheist participant, shame was frequently discussed in contexts where others had a high likelihood of being unsupportive or critical and where others used shame to enforce what International Perspectives in Psychology (2021), 10(1), 25–38

they considered appropriate behaviors or beliefs. For example, one woman explained, “So you know this is again now, we come to that filter [for right and wrong] that every person has. I think the Pakistani males have a filter you know that has bigger holes than females. So you know a lot of things that are not acceptable in society they would do it and get away just because they are a male, they would get away with that. And they don’t even feel ashamed about it because they feel that they are males and they are superior, and they can do it.” At the same time, the majority of women participants mentioned the disconnect between some cultural norms and religious rulings. While religion informs gendered interactions (e.g., modest dressing), women felt that the religion did not discriminate against them. Culture, rather than religion, gave women a lesser social status and led to more frequent experiences of shame for women than men. While culture was described as at times incorrectly using religion to justify women’s inferior social status, some women criticized and pushed back on cultural priorities using religious norms: “A husband would worry more of his wife talking to a male colleague rather than worrying more about that she prays 5 times a day. For example, if his wife is not praying five times a day, it is maybe not very much a problem for him. It is not a very shameful thing. I don’t think he will make her accountable for that. But it is a big sin if you are not praying, but it is okay for her husband. But if she talks a lot or she hangs out with his male colleagues or male friends, his husband would let her feel shame about it! This is the thing, yeah.” Social control can be exercised by both acquaintances and family members. Indeed, some parents “somehow think it is their fault too that the child behaved in a certain manner that is shameful and to please elders/friends/ peers they join those people in making the child feel bad.” Outside of the family, the social control is reinforced by the negative social consequences associated with the shamed behavior (e.g., not being invited to some family events and more difficulty getting married). A few participants mentioned violent reactions from family members and the violent social sanctions present in some (rural) parts of the country. Participants felt those sanctions and reactions reflected less mature and undesirable ways of dealing with shameful events that resulted in a family’s perceived loss of honor.

Analyze the Situation Some participants explicitly mentioned the need to analyze the situation, while others simply engaged in a detailed analysis when recounting an event during which they felt ashamed. This participant commented on the need to International Perspectives in Psychology (2021), 10(1), 25–38

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analyze the situation for the shameful event: “First of all I will adopt a proactive approach. For example, it depends. If, you know, it was a willful contribution, I will definitely have a 360-degree review of why I did that. Can I live without that? And you know I will take a different route. And if it was not willful, it was a forceful then to some extent you don’t have a control on that. Maybe you have to do it again for your survival.” Just like him, a subset of participants explicitly commented on the need to understand whether themselves or others had been forced by circumstances to commit a wrongdoing. Participants’ analyses seemed to focus on (a) whether the shame was due to a wrongdoing and (b) the context in which the incident occurred (e.g., in the presence of elders or others with more/less social status). They then devised a course of action based on their analyses. In that sense, how one deals with shame is not predefined and is a flexible and thoughtful reaction: “Obviously as you age you mature as a person you take more time to think about the situations and not just react on a whim.” Shame becomes a signal that stimulates analysis and self-reflection, and responses to shame are framed within a specific and often complex social world.

Positive Coping Strategies Participants commented on a number of positive coping strategies. The following four strategies were endorsed by the majority of participants: change/better the self, stop unwanted behaviors, share with close others, and accept and correct. A minority of participants specifically mentioned seeking protection with God (which was coded separately from repenting to God) and remove/act despite (mostly unjustified) shame. Most positively perceived coping strategies seemed to lead to self-change and selfimprovement; thus, both reinforcing and illustrating how shame could act as a beneficial signal of wrongdoing. Changing or bettering the self was used most frequently by participants after realizing they engaged in a wrongdoing. It was described as a potentially long and thoughtout process and as a benefit or outcome of shame if coped with successfully. While it could be as simple as making reparations to become like one wants to be, it more frequently occurred after a major transgression that required more time to be overcome (e.g., failing in university): “So I couldn’t really do anything else at that time to make others around me feel better so it was good in a sense that it got me thinking on what I needed to do to fix things in my life. So there was regret as well as some feelings of I don’t know uske liye thik word kia hoga [what word is the right word]. I just wanted to do something right. Although it took me 4 or 5 months to do it right but I had this feeling of wanting to © 2021 Hogrefe Publishing

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do something.” Some participants mentioned coming back “to the straight path,” meaning following one’s religious standards, and thus also implied a bettering of the self. One participant even reported using this coping strategy in the context of shame due to discrimination: “So it somewhere stuck in my mind that I am black, and it somewhere stuck in my mind that I am fat, oh my god, I look ugly. But I chose to be a better person instead! I worked hard, I studied hard. Today I am a mechanical engineer, all those people they are just wandering on streets and doing nothing. So it brought out the best in me.” Participants reported another positive outcome of shame was to inhibit unwanted behaviors in the short term (immediately when feeling ashamed) or long term (once the individual finds themselves again in a similar situation). It encourages individuals to avoid actions detrimental to others, the group, their spiritual growth, or to their standing within the group. This is qualitatively different than the urge to withdraw usually described in the Western literature. While withdrawal has been mainly construed in negative terms in Western contexts, participants in the current study saw something positive in shame inhibiting or stopping in their tracks undesirable behaviors: “This emotion can be good if it prevents a person to do wrong thing.” They only felt negatively about this coping strategy when it occurred due to problematic shame stemming from social control. While participants could take individual actions after feeling ashamed, many participants reported sharing their feelings of shame with family members, close friends, or God. Many participants felt that it was a normal part of their family culture or friend group to discuss shameful events. Others commented that they learned to share those events with others after marriage or after immigrating to Canada. A few still only shared those experiences with God. When doing so, participants elected to talk with supportive others who could act as allies, or who would benefit from learning about the outcomes of a particular behavior. For example, two participants commented, “Yes, I believe people can easily tell [that I feel ashamed]. Also, I feel comfortable explicitly talking about my faults with almost anyone,” and “Yes, I will speak with someone who is really close to me. Definitely I will speak because I would like this not to be happening in the future. So I will definitely discuss this in order to get a good advice.” Sharing was seen as a potential step toward bettering the self or helping other better themselves. Frequently, participants grouped together two strategies to overcome feelings of shame after a wrongdoing: accept and correct. While for some participants the effect was entirely prosocial (i.e., directed at improving the relationship with the other who was negatively impacted by one’s mistake), others only or almost exclusively accepted and repented their mistakes in the presence of God. The © 2021 Hogrefe Publishing

acceptance of one’s mistake appeared to be a prerequisite for repenting or repairing. From participants’ accounts, both culture and religion “tell us to repent whole heartedly, feel and say sorry if you wronged someone and promise to never repeat it again.” A subset of participants highlighted the important role played by God in their coping. A participant recited a verse to seek protection from others’ wrongdoings: “In those time, it is religious teaching that you recite a sentence. If you wanna know I can tell you “lahaulo wala quwata illa billa aliyulazeem” [There is no power nor strength except by Allah].” Others turned to God in repentance after their own acts of wrongdoing or followed the guidelines imparted by Islam to deal with shame (e.g., to seek protection with God and apologize). Finally, a number of participants also reflected on the need to at times remove feelings of shame or act despite them. Participants could act despite the shame if the intensity of the emotion was low or if they felt the shame was not justified (e.g., felt due to social norms the participant disagreed with). In the latter case, participants conceptualized their behavior as a positive form of shamelessness challenging unwanted social rules. For women, it could mean acting outside of appropriate gendered behavior or challenging Canadian norms they disagreed with: “I think that’s where you have to get out of that feeling, of feeling that if something is labelled wrong or right and you feel that it is not [right]. If it is unjustified than you should stand up against it.”

Negative Coping Strategies Most participants felt that withdrawing or hiding truth, or one’s views or actions was a negative coping strategy. Some participants also mentioned and consistently assessed negatively instances where individuals or society dealt with shame using anger or violence. Last but not least, they felt an inability to regulate shame could result in lack of confidence. For most participants, withdrawing or hiding the truth or one’s views or actions due to shame was qualitatively different from descriptions of stopping unwanted behaviors. While the latter was assessed positively, withdrawing/ hiding was accompanied with a sense of helplessness and occurred due to individuals becoming overwhelmed with their feelings of shame. Furthermore, rather than being preventative or holding the possibility to reduce future harm (like stopping unwanted behaviors), the harm has already been done to the person’s self-esteem or social standing. In the words of a participant, “I think in our community, like. . . to be. . . if you got cheated or you do something that would bring shame to your family, lot of people they won’t. . . just try to hide that thing for a long International Perspectives in Psychology (2021), 10(1), 25–38

time.” This action was frequently presented both as a commonly occurring reaction and a way of coping with the emotion which led to negative outcomes, such as isolation, and preventing a bettering of the self or society. For example, “People stop sharing, they keep things to themselves, they stop asking for help.” A little less than half of the participants mentioned instances related to anger or violence. This includes when they were angry (majority of instances) or were/wished to be physically violent (during their teenage years) after feeling ashamed, or instances in which families or communities, particularly in rural areas, may use (sometimes extreme) physical violence as a result of familial shame due to loss of honor. Participants felt the use of violence signaled more immature and undesirable coping: “[as a teenager], Yeah I got angry, I would lash out. That is what I would do, but now I understand things differently and I react differently.” Participants reported growing out of this response to shame as they aged and wished families no longer used violence in response to shame. Finally, a subset of participants mentioned that shame could also lead to an ongoing lack of confidence, if it was too present in the person’s life: “Shame deprives people from speaking the truth because they are scared how society will react if they are honest about an act they did or their views about something, it harms self-confidence and is source of oppression.” Thus, some participants spoke about how reoccurring experiences of shame in certain contexts (e.g., lack of supportive others) could lead to a lack of confidence in oneself over time.

Immigration As previously mentioned, slightly more than half of participants reported a decrease in the frequency of feelings of shame related to others since moving to Canada. Participants attributed this change to differences in cultural norms as well as the less relational and more individualistic context present in Canada. Additionally, four participants mentioned that they developed a better understanding of shame after immigration due to the opportunities provided in comparing different cultural norms and ways of experiencing and dealing with shame. One-third (N = 6) of participants reported no change in how frequently they experienced shame or in their understanding of shame after immigration.

Discussion The aim of the present study was to explore the beliefs about shame and coping strategies used by Pakistani International Perspectives in Psychology (2021), 10(1), 25–38

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immigrants to Canada. Participants’ accounts revealed a complex and nuanced understanding of the emotion and its relational and social context. Importantly, shame acted as a powerful signal to evaluate one’s action and the situation and assess whether one has been engaged in wrongdoings. Shame was thus intimately tied to morality and, for some participants, Islamic morality specifically. Shame acted as a motivator to better the self, sometimes over long periods of time, both through and in tandem with additional coping strategies including accepting one’s errors and correcting oneself or the situation, seeking protection with God, or sharing the incident with friends. Participants’ beliefs about shame allowed them to access a wide range of coping behaviors when feeling ashamed and led most participants to prioritize coping strategies which positively included others or focused on self-improvement. Participants also mentioned that shame could be handled negatively and named negative coping strategies such as withdrawing and hiding, as well as anger and aggression. Participants explained that shame could also result in an ongoing lack of self-confidence in some contexts. If, once the self-analysis was completed, shame was deemed to be due to unwanted social pressures, participants understood shame as existing within specific social hierarchies and a negative by-product of social control or having a lesser social standing. By exploring narratives about shame of Pakistani immigrants to Canada, without relying on Western definitions and theories of shame, this study expands our understanding of culturally situated discourses and metacognitions about shame. Indeed, within Western psychology, shame is mostly viewed as a painful, maladaptive emotion about the global self (e.g., “I am a horrible person”; Tangney, 1996; Tracy & Robins, 2004). While Western psychology mainly aims to identify innate and/or highly generalizable characteristics of shame experiences and their regulation (Tracy & Robins, 2004), its definition of shame and the associated distinction between shame and guilt (Tangney, 1996) echoes widely held beliefs in United States culture (Stearns, 2016). The self is mostly seen as stable or largely invariant (Nathanson, 1992). The multiplicity of identities held by every individual (Linville, 1987; Watcher et al., 2015) is largely ignored when studying shame, and the focus on shame as maladaptive has led to a very limited assessment of its adaptive features (de Hooge et al., 2011; de Hooge, 2013). While Western conceptualizations and measurement of shame have been used with other cultural groups, including Pakistanis (Shahnawaz & Malik, 2017; Taihara & Malik, 2016), they are likely to miss opportunities to explore culturally situated understandings of this emotion due to their narrow assumptions and focus (Shi-xu, 2009). Indeed, if we had uncritically applied Western theories, definitions, and © 2021 Hogrefe Publishing

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measures of shame to Pakistani immigrants to Canada, it is unlikely we would have both explored and highlighted the complexity, contextual nature, and nuance of beliefs about shame held by Pakistani immigrants to Canada. Culture can profoundly shape emotional experiences through ongoing interpersonal interactions, as well as cultural norms about emotional experiences and desirable behaviors (Boiger & Mesquita, 2012; Mesquita et al., 2017). For example, shame is more likely to be attended to by the ashamed individuals and coregulated with close others in Japan, where the emotion is socially valued, compared to the United States or Germany, where shame is typically associated with isolation and withdrawal (Boiger & Mesquita, 2012; Mesquita et al., 2017). Similar to accounts of Pakistani immigrants to Canada, shame is a painful yet socially valued emotional experience in China (Ho et al., 2004) and Taiwan (Wong & Tsai, 2007). The emotion benefits from a rich vocabulary (about 150 words are related to shame in China and Taiwan), some of which indicate shame can provide opportunities to improve the self (Bedford, 2004; Ho et al., 2004). It exists within culturally specific moral rules dependent on individuals’ relationships and status within those specific relationships (Hong, 2004; Mao-jin & Jing-jing, 2009). Furthermore, in China and Taiwan, it is predictive of individuals’ learning after failure (Wang et al., 2018) and of increased relationship building efforts (Wong & Tsai, 2007). Multiple non-Western groups thus not only hold more relational, nuanced, and positive evaluations of shame but also tend to positively engage with the emotion rather than withdrawing. The research findings of this study are important in contributing to the expansion of culturally sensitive research on shame and the regulation of shame both in different cultural groups and in immigrant populations. The findings from this study, in conjunction with the existing research on shame in China, Taiwan and Japan, have multiple theoretical implications. First, despite the multitude of scales measuring the emotion of shame, the most commonly used scales rely on Western definitions of shame which provide a very limited assessment of the emotion’s adaptive features and largely ignore relational and spiritual contexts (de Hooge et al., 2011; de Hooge, 2013; Collardeau et al., 2020). Recognizing the influence of culture on shame’s frequency or triggering event only (e.g., Tangney et al., 2007; Tracy & Robins, 2004) rather than on the wider experience of shame (i.e., cognitions, expression, and emotion regulation strategies) is limiting. The search for highly generalizable and parsimonious measures and theories may miss meaningful and important qualitative differences in emotional experiences and assumes (without checking empirically) that participants with different cultural backgrounds and life experiences will interpret items in the same way. Indeed, should we © 2021 Hogrefe Publishing

expect a Pakistani immigrant to Canada to understand and rate a Western scale’s items in the same way as a Canadian of European descent? Or should we ask Pakistani immigrants to Canada to ignore part of their beliefs and experiences with shame to respond to items not generated to be culturally sensitive to their cultural background? Even quantitative studies done in the West should strive for a greater attention to cultural, relational, and spiritual factors. This may be done through, for example, a greater attention to metacognitions and religious beliefs or through statistical analyses, such as measurement invariance analyses (Sakaluk, 2019), to quantitatively illuminate qualitative differences in meaning-making. Second, Pakistani immigrants in our study possessed a high level of awareness regarding the role of shame in perpetuating social and cultural norms, as well as social hierarchies. This needs to be further examined for both Pakistani immigrants to Canada and other immigrant groups, as it may influence how individuals negotiate conflicting social norms between the majority culture and their own cultural background and make sense of discrimination, microaggression, and other messages devaluing their own cultural traditions. The findings of this study have important implications for practitioners in their work with Pakistani immigrants to Canada, as well as other groups who may not hold Western beliefs about shame. It is important for practitioners to work from a place of cultural humility (Buchanan et al., 2020; Case, 2015; Tervalon & Murray-Garcı́a, 1998), especially when helping clients’ process negative and painful emotions like shame. Therapists should be aware of and curious about beliefs about shame which differ from the usual mainstream Western definition of shame present in the literature and be open to the possibility that other understandings of the emotion may result in more positive coping strategies and even self-improvement. While Pakistani immigrants to Canada also discussed maladaptive aspects of the emotion, when it came to social control, it was balanced with a belief in the helpful and adaptive nature of shame and its role in helping individuals become moral members of their community. Pakistani immigrants to Canada’s positive beliefs about shame and proactive stance toward the regulation of shame are likely to be protective factors in their immigration journey. More specifically, their awareness of power imbalances in relationships and society may be helpful in making sense and dealing with the discrimination they experience in Canada. Thus, therapists should be careful not to shut down some helpful coping strategies, including reaching out to close others to get advice on one’s action or a situation which triggered shame. It is important to honor clients’ cultural and religious knowledge about the emotion. It may be especially harmful for clients with a nuanced and complex understanding of shame to have International Perspectives in Psychology (2021), 10(1), 25–38

their therapist overly focus on the distinction between shame and guilt or imply a narrow view of the emotion as being only maladaptive. We would also like to encourage therapists to be open to discussing sources of shame (e.g., personal vs. imposed by others) and systemic, structural inequalities which may be important in explaining individuals’ emotional experience. For our participants, problematic shame was very much conceptualized as a result of social inequalities due to aspects of identity such as gender or socioeconomic status. Despite the valuable insights into beliefs about shame and coping strategies used by Pakistani immigrants to Canada, this study has some limitations. First, Pakistanis and the Pakistani diaspora in Canada are culturally, linguistically, and economically diverse. While participants’ interviews suggest some diversity in social status (including participants from rural areas of Pakistan) both before and after immigration, it is not information that was collected in detail as part of the study. This study represents the experiences of some, but not all, Pakistani immigrants to Canada. It is also important to note that, just like with any other group, wide differences in beliefs about shame and coping strategies are likely to exist for individuals who are Pakistani immigrants to Canada. Although generalizations should be approached with caution, this study still achieved a deeper and more culturally specific understanding of shame from the perspective of Pakistani immigrants to Canada. Second, this study is limited in its exploration of context, both relational and structural, that would inform how Pakistani immigrants to Canada understand and deal with experiences of shame in their daily life postimmigration. A greater exploration of contextual factors would be beneficial to understand what helps or hinders the regulation of shame both before and after immigration. Additional research is necessary to expand current definitions of shame to render them more inclusive of non-Western worldviews and honor the diversity in metacognitions or beliefs about shame present in different groups (Collardeau et al., 2020). With Pakistani immigrants to Canada specifically, it may be especially fruitful to explore gender differences in the experience of shame, as well as to further explore how context, relationships, and social status influence both the meaning given to situations and individuals’ coping strategies. The findings from this study provide a more nuanced and culturally sensitive understanding of how Pakistani immigrants to Canada think about and cope with shame. It also highlights the need to decolonize the study of emotions and emotion regulation more generally to move toward research designs that do not exclusively rely on Western definitions and measurements and that allow for a more holistic, culturally sensitive study of emotions. International Perspectives in Psychology (2021), 10(1), 25–38

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Williams, E. N., & Morrow, S. L. (2009). Achieving trustworthiness in qualitative research: A pan-paradigmatic perspective. Psychotherapy Research, 19(4–5), 576–582. https://doi.org/10.1080/ 10503300802702113 Wong, Y., & Tsai, J. (2007). Cultural models of shame and guilt. In J. L. Tracy, R. W. Robins, & J. P. Tangney (Eds.), The selfconscious emotions: Theory and research (pp. 283–309). Guilford Press. History Received September 26, 2020 Revision received December 28, 2020 Accepted December 30, 2020 Published online February 17, 2021 Acknowledgments The authors would like to thank Sydney Witoski for being a second coder for this study. Conflict of Interest The authors declare no conflict of interest. Funding The first author received a Grant-In-Aid from the Society for the Psychological Study of Social Issues for this work. ORCID Fanie Collardeau  https://orcid.org/0000-0002-9936-2372 Fanie Collardeau Department of Psychology University of Victoria Victoria, BC Canada faniecol@uvic.ca

Article

Massacre, Earthquake, Flood Translational Science Evidence That the Use of Micronutrients Postdisaster Reduces the Risk of Post-Traumatic Stress in Survivors of Disasters Julia J. Rucklidge1, M. Usman Afzali1, Bonnie J. Kaplan2, Oindrila Bhattacharya1, F. Meredith Blampied1, Roger T. Mulder3, and Neville M. Blampied1 University of Canterbury, Christchurch, New Zealand

Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

School of Medicine, University of Otago, Christchurch, New Zealand

Abstract. Natural (e.g., earthquake, flood, wildfires) and human-made (e.g., terrorism, civil strife) disasters are inevitable, can cause extensive disruption, and produce chronic and disabling psychological injuries leading to formal diagnoses (e.g., post-traumatic stress disorder [PTSD]). Following natural disasters of earthquake (Christchurch, Aotearoa/New Zealand, 2010–11) and flood (Calgary, Canada, 2013), controlled research showed statistically and clinically significant reductions in psychological distress for survivors who consumed minerals and vitamins (micronutrients) in the following months. Following a mass shooting in Christchurch (March 15, 2019), where a gunman entered mosques during Friday prayers and killed and injured many people, micronutrients were offered to survivors as a clinical service based on translational science principles and adapted to be culturally appropriate. In this first translational science study in the area of nutrition and disasters, clinical results were reported for 24 clients who completed the Impact of Event Scale – Revised (IES-R), the Depression Anxiety Stress Scales (DASS), and the Modified-Clinical Global Impression (M-CGI-I). The findings clearly replicated prior controlled research. The IES-R Cohen’s d ESs were 1.1 (earthquake), 1.2 (flood), and 1.13 (massacre). Effect sizes (ESs) for the DASS subscales were also consistently positive across all three events. The M-CGI-I identified 58% of the survivors as “responders” (i.e., self-reported as “much” to “very much” improved), in line with those reported in the earthquake (42%) and flood (57%) randomized controlled trials, and PTSD risk reduced from 75% to 17%. Given ease of use and large ESs, this evidence supports the routine use of micronutrients by disaster survivors as part of governmental response. Keywords: disasters, psychological injuries, micronutrients, earthquake, flood, mass shooting Impact and Implications. Disasters, both natural (e.g., earthquakes, floods) and human-made (e.g., terrorism, civil strife), affect communities worldwide, often causing immense disruption and suffering, and lasting psychological injuries. Following the mass shooting in mosques in Christchurch, NZ, in March 2019, micronutrients (vitamins and minerals) were offered to survivors as a clinical service, and results replicated controlled research in the aftermath of an earthquake and a flood that showed that providing survivors with micronutrients reduced psychological distress, to a clinically significant degree, immediately and at one-year follow-up. This research promotes the achievement of the United Nations Sustainable Development Goals number 2 (improve nutrition) and number 3 (ensure healthy lives and promote well-being).

Disasters, both natural and human-made, have been experienced by humankind throughout history. However, despite our collective understanding of the inevitability of such events, when disasters do occur, they always cause distress, and the trauma may be severe for some individuals in the affected population. A sudden disaster that brings threats to well-being and survival evokes an array of defensive responses, often described as the fight/flight response (Rego et al., 2009), with associated physiological, cognitive, and emotional reactions that prepare survivors to evaluate the threat and organize themselves for avoidance, confrontation, or

escape; these responses are accompanied by emotions such as fear and anxiety (Baldwin, 2013; Craske et al., 2006; Sherin & Nemeroff, 2011). The immediate and longer-term psychological distress individuals feel following a disaster can include prolonged and/or intense anxiety and fear, depression, dissociation, hypervigilance, flashbacks, and extreme irritability (Baldwin, 2013), although there is great individual variability (Bonanno et al., 2010, 2011; Dickstein et al., 2010). When symptoms of distress become severe and prolonged, individuals may develop diagnosable disorders such as acute stress disorder, post-traumatic stress

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disorder (PTSD), major depressive disorder, and general symptoms of post-trauma stress (American Psychiatric Association, 2013). Following a disaster, rates of PTSD can range from 30% to 60% of those exposed and can persist for up to one-third of those affected 2 years postevent (Galea et al., 2005); some may continue to experience symptoms for years, even decades. This is much higher than the general lifetime prevalence of PTSD of ∼7% (Kessler et al., 2012). Thus, whatever the nature, scale, and duration of a disaster, psychological injuries will be among the many serious challenges facing individuals, communities, and health systems. Indeed, O’Connor et al. (2011) observed that “Of all the many physical, social, environmental, and economic aspects of natural disasters, the psychological dimension is arguably the most important to humans.” (p. 2). While in the immediate disaster aftermath the treatment of physical injuries will likely dominate the health response, psychological distress and its chronic sequelae will become more important as time goes on (Deely & Ardagh, 2018). While distress is an expected consequence of disasters, it is difficult to predict who will be individually vulnerable to it, especially in the form of PTSD and other diagnoses, and who will be resilient. Factors known to increase the risk of prolonged distress include severity of any injuries to self and important others, level of social support, age, personality factors, emotional states, early life experiences, level of destruction of homes and other places of personal, economic and social importance, and general loss of resources (Bonanno et al., 2010, 2011; Orcutt et al., 2014). However, given that these predictors are neither highly reliable nor necessarily easy to determine case by case in the immediate event aftermath, any postdisaster intervention that can be delivered safely and immediately to a wide range of survivors will likely produce substantial benefits in reducing distress and preventing serious disorders such as PTSD.

Triage Theory and the Role of Nutrition Postdisaster A factor that has been largely overlooked in extant disaster/trauma research is the adequacy of the postdisaster food and nutritional environment to meet the nutritional needs of highly stressed survivors. There are several factors that are relevant here. First, the disaster may disrupt food supplies and make access to food in general, and especially food of high nutritional quality, difficult. Second, dietary choices tend to change in the wake of a disaster toward selection of “comfort foods” (Kuijer & Boyce, 2012), so even those with access to highInternational Perspectives in Psychology (2021), 10(1), 39–54

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quality food may experience a reduction in the nutritional quality of their diet as a function of their individual choices. Third, there are individual differences in metabolic needs for various dietary components (Kaplan, Rucklidge, Romijn, & McLeod, 2015), making some individuals especially vulnerable to postdisaster nutritional insufficiency, irrespective of general food supply adequacy and individual food choice. Of particular concern are the food components, vitamins and minerals (collectively, micronutrients), since these are essential for the daily operation of biochemical reactions that occur throughout the body, including the brain. Among other functions, micronutrients provide the essential cofactors/catalysts required to synthesize neurotransmitters, support the function of the citric acid cycle (which is essential for the production of energy), assist with modulating inflammatory responses, and are essential for ensuring that methylation occurs, a process which ensures the regulation of the cardiovascular, neurological, reproductive, and detoxification systems (Kaplan, Rucklidge, Romijn, & McLeod, 2015). All of these key metabolic activities require that the food individuals consume reliably supplies the necessary micronutrients. It follows from this that any impairment of the postdisaster diet, for whatever reason (see above), may weaken the capacity of individuals to cope with and adapt to the prolonged stress characteristic of such situations. This is highlighted by triage theory (McCann & Ames, 2009). Triage theory identifies how intrinsic internal systems ensure that the micronutrient-dependent physiological functions required for short-term survival (like the fight/ flight response) are metabolically protected at the expense of longer-term functions (such as cognitive processing and emotion regulation). In coping with immediate threats, the body diverts resources from homeostatic physiological processes (such as gut function) to meet urgent survival needs (such as increased cardiac and adrenal output), thereby prioritizing short-term survival over long-term adaptive coping. Triage theory thus predicts that, during and after a disaster, nutrients are redirected to the individual’s stress response, leaving limited nutritional resources to be shared with other functions. Over time, and given persisting stress, this prioritization in favor of shortterm survival may reduce or impair methylation processes that in turn may damage DNA and contribute to mitochondrial decay (Ames, 2010), all processes identified as important to mental health. Thus, as an individual’s nutritional reserves that support the flight/flight response are depleted – because available foods are less nutritious, or because of ongoing choice of less nutritious food, and/or because of individual metabolic differences in nutrient needs – triage theory suggests that the person may experience a nutritional deficit that © 2021 Hogrefe Publishing

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could compromise other adaptive functioning such as emotion regulation, cognition, and social functioning (Kaplan, Rucklidge, Romijn, & McLeod, 2015). Note that triage theory does not require nutritional deficiencies to reach the point of causing overt physical symptoms (e.g., scurvy); Ames (2010) has hypothesized that even small or subtle deficiencies in one or more nutrients may lead to significantly poorer long-term outcomes if the stress experienced is chronic in nature.

Evidence for B Vitamins in Alleviating Stress Triage theory predicts that increasing the supply of essential nutrients during a time of high stress should have a positive effect on coping and resilience, a prediction based, in part, on the known biochemical roles that B vitamins play in moderating the stress response. B vitamins are known to play a prominent role in methylation, neurotransmitter synthesis, energy production, glucose metabolism, and inflammation reduction (Kennedy, 2016). Furthermore, there is now research, including randomized placebo-controlled trials, in settings such as workplaces and among healthy community volunteers, which has consistently shown that increasing B vitamin intake improves resilience as shown by greater reductions in reported stress in the B vitamin groups compared with placebo groups (Schlebusch et al., 2000; Stough et al., 2011; White et al., 2015). Two meta-analyses have confirmed the stress-reduction benefits of B vitamins (compared with placebo); reported between-group effect sizes (ESs) range from 0.23 to 0.35 (Long & Benton, 2013; Young et al., 2019). Based on the Chambless and Hollon (1998) criteria for a well-established treatment, B vitamins, as treatment for reducing stress, meet those criteria. While these ESs are small, the majority of the samples were healthy volunteers; effects tend to be larger when targeting clinical samples (Blampied, Bell et al., 2020). As additional evidence of the effect of B vitamins on stress, biological markers, such as nutrient concentrations (Armborst et al., 2018; Camfield et al., 2013), have been shown to increase significantly in line with reduction in reported stress levels, supporting the biochemical role these nutrients play in improving mental health.

particular kind of event inducing the stress (Chrousos, 2009). Consistent with this, research by the Mental Health and Nutrition Research Laboratory (University of Canterbury) has identified broad-spectrum micronutrients (vitamins and minerals, including but not limited to B vitamins) as an aid in recovery from the stress associated with natural disasters. This research was initiated in the aftermath of a severe earthquake sequence that began in September 2010 in the Canterbury (Aotearoa/New Zealand) region, ultimately destroying much of the city of Christchurch. After the initial earthquake, Rucklidge and Blampied (2011), exploiting a natural experiment where the timing of the earthquake relative to participation in a clinical trial fortuitously created control and treatment groups, reported that trial participants who happened to be taking micronutrients at the time of the September 4, 2010, earthquake (magnitude 7.1) recovered more quickly in the first two weeks postearthquake than the people who were not taking the nutrients. Following a severe aftershock (magnitude 6.3) in this sequence in February 2011, which killed 185 people and caused further major damage to the city, 91 adults volunteered for a randomized controlled trial (RCT) and were randomized to receive either B vitamins or a low or high dose of broad-spectrum micronutrients, and there was also a nonrandomized treatment-as-usual (TAU) group (n = 25) who were identified as being similar in demographic characteristics and symptom severity at baseline as the treated groups (Rucklidge et al., 2012). Relative to the TAU group, all three nutrient treatments resulted in a clinically and statistically significant reduction in reported stress and anxiety (ds ES relative to TAU ranged from 0.4 to 0.88) and improved mood, with mean scores changing from moderate–severe baseline levels into the normal/nonclinical range. For the TAU group, in contrast, there was very little change over time (e.g., dav for change in post-trauma stress pre–post = 0.14). The higher dose of micronutrients (eight capsules per day) showed the most benefit relative to the comparison supplements, in that more people taking the high dose reported greater improvement in mood, anxiety, and energy, with twice as many reporting being “much” to “very much” improved compared with the B-vitamin group. Those taking the micronutrients also reported fewer intrusive thoughts related to the trauma than did the B-vitamin recipients. In addition, rates of probable PTSD in the nutrient groups (identified by a score ≥33 on the Impact of Event Scale – Revised (IES-R; Weiss & Marmar, 1997) dropped from 65% to 19% compared with no change in the TAU group (which stayed at about 48%). These clinical advantages for the treated groups were maintained at a 1-year follow-up (Rucklidge, Blampied et al., 2014). International Perspectives in Psychology (2021), 10(1), 39–54

Following the same earthquake, beneficial effects of micronutrients were also observed for 14 children aged 8–11 years with pre-existing anxiety disorders which were exacerbated by the disaster. They showed large reductions in anxiety and emotional distress (ESs > 1) following 8 weeks consumption of the same micronutrient formula as used in the adult RCT (Sole et al., 2017), in a multiplebaseline across participants design. These positive effects of nutrients on stress were replicated in a further RCT following a flood in Alberta, Canada, in June 2013, which resulted in five deaths, the evacuation of over 70,000 people, and extensive damage to the city of Calgary and adjacent communities (https://en.wikipedia.org/wiki/2013_Alberta_floods). Kaplan, Rucklidge, Romijn, and Dolph (2015) recruited 56 flood-affected adults in Alberta who were suffering from heightened depression, anxiety, and/or stress following the flood, and who had no prior history of mental disorders. They were randomized to receive B vitamins, the same micronutrient formula used in the earthquake RCT, or 1,000 IU of vitamin D (an active comparator treatment). The B vitamins and micronutrients both resulted in significant improvements in reported psychological distress compared to the modest improvements following vitamin D (between-group ds > 0.8; a conventionally large ES; Lakens, 2013). The conclusion that can be drawn with at least modest confidence from this series of controlled studies, involving different natural disasters in different countries, and examining the effects of a range of nutrient treatments for both adults and children suffering psychological distress following the disaster, is that micronutrient supplementation delivers observable clinical benefits through reduction in symptoms of psychological distress.

The Translation of Research to Practice Following a Massacre On March 15, 2019, a gunman (a self-proclaimed white supremacist) successively entered two mosques in Christchurch (Aotearoa New Zealand) while worshipers were engaged in Friday prayers and killed 51 people and injured 40. The attack was live-streamed by the gunman on Facebook; an unknown but very large number of people worldwide, including children, viewed it despite attempts to remove it from the internet (see https://www. classificationoffice.govt.nz/news/featured-classificationdecisions/christchurch-mosque-attack-livestream/). This was a disaster that very seriously impacted the local Muslim community, the entire citizenry of Christchurch, International Perspectives in Psychology (2021), 10(1), 39–54

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and many people in the wider nation, and, because many members of the community were immigrants and refugees, had negative effects across the world (see https://theconversation.com/nz/topics/christchurchmosque-shootings-67899). The causes and consequences of this event were of great concern to psychologists nationally (and, indeed, elsewhere; see the special issue of the New Zealand Journal of Psychology, 48(1), April, 2019). Locally, in the immediate aftermath of the shootings, the researchers in the Mental Health and Nutrition Research Laboratory faced a compelling scientific and ethical dilemma: How best to use the knowledge reviewed above, about nutritional supplementation gained from previous studies on disasters, to help the survivors of this latest catastrophe? The research group chose to implement the research findings as a minimally sufficient clinical service (Blampied, Mulder et al., 2020) as an example of translational science (Reich, 2008); that is, turning research into practice so that new treatments based on research knowledge reach those who need the treatment (Woolf, 2008). This clinical work was facilitated through senior university students who were able to work in a culturally appropriate way with members of the affected community (authors M.U.A. and O.B.; see Electronic Supplementary Material, ESM 1, for more information on their role) and was conducted in accordance with the Declaration of Helsinki and the ethical standards applying in Aotearoa New Zealand to physicians and psychologists. Relevant university and health system ethics committees later granted clearance to publish our clinical observations. We report these here while also providing context by presenting reanalyses of relevant data from the earthquake and flood RCTs using the measures common across all three events, namely, the IES-R (Weiss & Marmar, 1997), the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995) and the Modified-Clinical Global Impression scale (M-CGI-I; Spearing et al., 1997). We were aware that the use of psychological measures such as these across different national communities and cultural and religious groups raises issues regarding the cultural generality of such measures (Byrne, 2016). We used the IES-R, the DASS-21, and the M-CGI-I because they permitted direct comparisons with our prior research, but considerable research has established that the IES-R and the DASS, both in English and in translation into languages used in Islamic-majority countries, retain their psychometric structure (e.g., the three-factor solution for the DASS; Asghari et al., 2008; Sariçam, 2018) and validity (e.g., the diagnostic domains of PTSD; Othman et al., 2016; Smith et al., 2003; Weiss, 2007), although there may be variation in the weighting given to specific components across cultures (King et al., 2009; © 2021 Hogrefe Publishing

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Zanon et al., 2020). The M-CGI-I is a self-rating of perceived improvement, thus permitting respondents to report their own judgment of any change in their state relative to their own cultural viewpoint. The approach deployed in our work entailed three logical steps: First, we drew on the data from the B-vitamin literature as well as the earthquake and flood RCTs to identify the treatment condition that was clearly superior to the placebo and/or active control and comparison conditions in those studies. This gave us substantive evidence for recommending a particular micronutrient formulation to massacre survivors. Second, we used inductive generalization to predict that what had benefited the survivors of the prior disasters would benefit the massacre survivors. Third, we gathered clinical data that might (or might not) confirm our inductive generalization when it was directly compared with that obtained in the prior RCT research (Barlow et al., 1984; Haig, 2014), and which also permitted us, clinically, to monitor response to treatment and any adverse effects and to respond to any such events appropriately. For ethical reasons, there was no direct control possible for the mosque shootings, but the results were compared with the findings from controlled research, where the evidence is that the micronutrients were beneficial. If the prediction is confirmed that the survivors of the shootings would experience benefit similar to that shown in the RCTs, there is support for the conclusion that the nutrients were the common source responsible for the benefit. As a matter of further generality, the data relating to the massacre are also the first observations of the effect of a nutritional intervention on a human-perpetrated disaster as compared to natural disasters (Galea et al., 2005), as well as being the first instance of a translational science approach to the deployment of a nutritional intervention postdisaster.

Method Clients Twenty-six adult clients began treatment between April 15 and May 27, 2019 (i.e., within 1–2.5 months of the massacre). They sought treatment through the liaison team members, having learned via word of mouth in the community or various services (e.g., Christchurch Resettlement Services, Muslim Association of Canterbury, and Anxiety Disorders Service) that donated micronutrients were available for anyone who was either directly (present in one of the mosques) or indirectly (a family member had been injured or killed) involved in the mass shooting. A © 2021 Hogrefe Publishing

majority were male (N = 17 of 26; 65%), aged 19–58 years old (M = 39, SD = 10.6 years), and nine were present in one of the two affected mosques at the time of the shootings. There was a broad range of nationalities/ethnicities represented, including people identifying as Pakistani, Indian, Afghan, Ethiopian, and Somali as well as New Zealand European.

Treatment Clients were provided with micronutrients in the form of Optimal Balance (Hardy Nutritionals) capsules by one of the authors (M.U.A. or O.B.). This is a broad-spectrum micronutrient formula (see Table 1 for the ingredient list) very similar to EMPowerplus (EMP+) used in the prior RCTs. It was classified as halal and could be taken outside of the Ramadan fasting (which fell during the clinical observation period). The manufacturer recommends three capsules be taken twice per day with food and ample water.

Clinical Procedures For the massacre clients, as is consistent with clinical practice, there was no randomization to any treatment condition, there was no control condition, there were no selection or exclusion criteria imposed (beyond those noted above), and neither the daily dose nor the duration for which the capsules were consumed was prescribed. Clients were recommended to follow the manufacturer recommended dose, but some people took more, some less, and those concurrently taking other treatments, including medication, were advised to discuss their micronutrient consumption with their physician/health provider. All clients were given information about possible side effects of micronutrients and about other treatment options, and they gave full informed consent to treatment (and any later dissemination of anonymized information). A physician (R.M., a psychiatrist) provided medical oversight as required. Informed consent was obtained when the capsules were delivered and when clients completed the online questionnaire. Completing the questionnaire provided a record of consent, some demographic information, and baseline and subsequent information about the clients’ psychological state, as the clients were asked to revisit the website and complete the psychological measures and report any side effects every 2 weeks. Reports were monitored to detect any response to treatment and any adverse side effects. When clients contacted the team and asked for more Optimal Balance, they were asked to continue completing the online questionnaire at 2-week intervals International Perspectives in Psychology (2021), 10(1), 39–54

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Table 1. Ingredients in Optimal Balance Ingredients in Optimal Balance

Amount/serving (three capsules)

Amount/day (six capsules)

Vitamin A (as retinyl palmitate)

2,000.0 IU

4,000.0 IU

Vitamin C (as ascorbic acid)

150.0 mg

300.0 mg

Vitamin D (as cholecalciferol)

1,500.0 IU

3,000.0 IU

Vitamin E (as D-alpha tocopheryl succinate)

35.0 IU

70 IU

Vitamin K1 (as phylloquinone and menaquinone-7)

60.0 mcg

120.0 mcg

Thiamin (as thiamin mononitrate)

27.0 mg

54.0 mg

Riboflavin

8.0 mg

16.0 mg

Niacin (as niacinamide)

26.0 mg

52.0 mg

Vitamin B6 (as pyridoxine hydrochloride)

24 mg

48.0 mg

Folate (as folic acid and L-methylfolate calcium)

400.0 mcg

800.0 mcg

Vitamin B12 (as methylcobalamin)

168.0 mcg

336.0 mcg

Biotin

318.0 mcg

636.0 mcg

Pantothenic acid (as D-calcium pantothenate)

14.0 mg

28.0 mg

Calcium (as chelate)

303.0 mg

606.0 mg

Iron (as chelate) – for women

13.5 mg

27.0 mg

Iron (as chelate) – for men

4.0 mg

8.0 mg

Phosphorus (as chelate)

193.0 mg

386.0 mg

Iodine (as chelate)

120.0 mcg

240.0 mcg

Magnesium (as chelate)

137 mg

274.0 mg

Zinc (as chelate)

11 mg

22 mg

Selenium (as chelate)

46 mcg

92.0 mcg

Copper (as chelate)

1.6 mg

3.2 mg

Manganese (as chelate)

2.2 mg

4.4 mg

Chromium (as chelate)

143.0 mcg

286 mcg

Molybdenum (as chelate)

33.0 mcg

66.0 mcg

Potassium (as chelate)

55.0 mcg

110.0 mg

Other ingredients: choline, coenzyme Q10, β-sitosterol, tocopherol, mineral wax, spirulina, larch arabinogalactan, inositol, Rhodiola rosea root extract, alpha lipoic extract, bamboo shoot extract, Astragalus root extract, royal jelly, grape seed extract, Ginkgo biloba leaf extract, boron (as chelate), vanadium (as chelate), lithium orotate (as chelate), nickel (as chelate) vegetarian capsule, microcrystalline cellulose, magnesium stearate, and silicon dioxide.

and another supply was delivered personally or mailed. Clients decided when they ceased treatment and when they stopped providing information online. Further detail of the clinical service work is provided in ESM 1.

Measures The measures completed online were 1. The IES-R (Weiss & Marmar, 1997): The IES-R is a 22item measure of commonly experienced symptoms following a distressing event. This scale is widely used in different cultures and following exposure to various traumatic events including, but not limited, to natural disasters like hurricanes (Dougall et al., 1999; Ironson et al., 1997), and earthquakes (Asukai et al., 2002; Wang et al., 2010). There are three IES-R subscales, namely, intrusion (eight items), avoidance International Perspectives in Psychology (2021), 10(1), 39–54

(eight items), and hyperarousal (six items), but these have not consistently emerged as factors in psychometric research (Creamer et al., 2003) and we only used the total score. A total score of ≥33 has been identified as a cutoff for probable PTSD, while a score of ≥24 indicates a basis for clinical concern. 2. The DASS – Short Form (DASS-21; Henry & Crawford, 2005; Lovibond & Lovibond, 1995): The DASS is a 21-item questionnaire that assesses an individual’s current severity of symptoms relating to depression, anxiety, and stress; scores are doubled to match the long form. Cutoff scores indicative of at least mild symptom levels are >9 for depression, >7 for anxiety, and >14 for stress; for moderate severity, these scores are >12, >9, and >18, respectively (see www.psy. unsw.edu.au/groups/dass). 3. The M-CGI-I scale (Spearing et al., 1997): The M-CGII asks individuals to rate their condition from 1 (very © 2021 Hogrefe Publishing

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much improved) to 7 (very much worse) and how much better/worse they were feeling since taking the micronutrients. Standard practice identifies those who endorse “much to very much improved” as “responders.” It was not completed before treatment. 4. Side effects: All individuals were asked to identify whether they had experienced any commonly reported symptoms (e.g., dry mouth, nausea, and constipation) from a list of possible side effects. They were also asked to comment whether they had noted any other adverse effects from taking the capsules.

Results In comparing data from these events, it is worth recalling that the mosque shooting was one brief event, the flood was one event lasting some days, and the earthquake involved a sequence of severe shocks and aftershocks over many months; of course, all had long-term impacts. Summary data from the three disasters are presented in Table 2. Individual responses are presented in modified Brinley plots (Blampied, 2017). These plots are a form of scatterplot, where each individual’s score at a later time is plotted against their score at an initial time, generally baseline. If there is little or no change over time, all data points will lie on or near the solid 45° diagonal (the line of no effect); treatment effects are shown as systematic deviations of the data points above and below this line. A second (dashed-dotted) line at 45° below the no-effect line shows the lower limit of the Reliable Change Index (RCI; Jacobson & Truax, 1991); points at or below this line are unlikely (p < .05) due to measurement error alone. The RCI for the IES-R was calculated from data in Creamer et al. (2003; Cronbach’s α = .96) and those for the DASS from Henry and Crawford (2005; α = .88, .82, and .90 for Depression, Anxiety, and Stress, respectively). The plots also show relevant clinical cutoffs (see Measures) as vertical and horizontal lines. The figures show additional information by way of the number of cases (N1) and the ES Cohen’s d and its 95% CI2 (calculated for pre-to-post data using software provided by Cumming [2012]; see also Lakens [2013]). A second ES is also reported, the percent superiority (PS) ES, which gives the probability that any randomly selected case has a clinically better score post-

treatment than at baseline (Lakens, 2013). These two ES measures complement each other in that one (d) is a standardized mean difference, and the other (PS) an estimate of likelihood of change for any case. The data are shown separately for men and women, due to likely interest in any gender effects, both on initial trauma symptom response and in response to treatment, although this gender split does not yield subgroup Ns large enough for further statistical analysis. Of the 26 individuals who experienced the 2019 mass shooting and sought our clinical service, 24 completed at least two questionnaires, one before treatment and one between 2 and 8 weeks after beginning the treatment. Most took about six capsules per day (the recommended dose; average dose was ∼five capsules per day, a dose comparable to the dose used in the RCTs), and side effects were reported infrequently if at all and were mild (e.g., dry mouth, headache, and constipation), all of which were resolved by taking the capsules with ample food and water or reducing the dose. Two people chose to discontinue treatment because of trouble swallowing the capsules. Three people reported to us that they also sought help from a counselor while taking the capsules.

Mosque Client Trauma Results Figure 1 shows IES-R data for the 24 mosque clients. In contrast to the earthquake and flood data (see below), there were substantially more men than women consuming the supplement after this event. What Figure 1 shows most conspicuously is that at baseline (i.e., after the experience of the massacre but before nutritional supplements were consumed), the IES-R scores of the clients fell into two clear groups. Six cases (one a woman) had low scores, all below the threshold of clinical concern. The rest all had scores to the right of the vertical clinical cutoff line indicative of possible PTSD. At the last observation (at which point, clients had taken different doses for varying durations of consumption, but for a minimum of 2 weeks), the six cases in the low IES-R score group at baseline showed little change. However, for those above the likely PTSD threshold pretreatment, all but three (all men) showed a reduction in scores to be at or below that threshold (shown as the solid horizontal line), with 10 cases being even below the lower cutoff for clinical

This N is generally smaller than the total N reported for the respective study because only those cases with data at both specific time points can be plotted. Note that if the 95% CI on d does not cross zero, then a t-test on the corresponding means would be statistically significant, p < .05. d may also be said to be “statistically significant,” meaning that the null hypothesis that d = 0 can be rejected at the stated alpha level (p < .05).

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Table 2. M, ranges, and SD at baseline and last observation for the Impact of Event Scale – Revised, and Depression, Anxiety, and Stress from the Depression Anxiety Stress Scales 95% CI

Range M

Lowest

Highest

dav

Lower

Upper

Percent superiority

Impact of Event Scale – Revised Total Score Massacre N = 24 Baseline

Last observation

41.2

20.13

21.2

14.93

31.1

11.88

1.13

1.7

0.52

81%

1.2

1.88

0.53

90%

1.1

1.6

0.57

84%

1.2

1.8

0.56

82%

1.05

1.7

0.36

81%

0.83

1.3

0.34

77.5%

1.12

1.73

0.5

79%

1.05

1.7

0.38

79%

0.88

1.275

0.48

86%

Flood N = 14 Baseline

Last observation

16.4

12.24

39.95

15.66

Earthquake N = 26 Baseline

Last observation

21.62

17.89

Depression Anxiety Stress Scales – Depression Massacre N = 24 Baseline

Last observation

17.1

5.6

12.44

5.37

2.6

Flood N = 18 Baseline

Last observation

8.3

3.2

16.12

8.69

Earthquake N = 26 Baseline

Last observation

9.04

8.44

Depression Anxiety Stress Scales – Anxiety Massacre N = 24 Baseline

Last observation

15.08

11.17

5.33

5.13

8.67

7.2

Flood N = 18 Baseline

Last observation

2.6

11.15

3.2

Earthquake N = 26 Baseline

Last observation

4.62

7.54

7.28 (Continued on next page)

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Table 2. (Continued) 95% CI

Range M

Lowest

Highest

Lower

Upper

Percent superiority

1.1

1.7

0.51

82%

1.37

2.1

0.65

88%

1.2

1.7

0.67

87%

dav

Depression Anxiety Stress Scales – Stress Massacre N = 24 Baseline

7.97

9.9

8.3

6.99

22.1

8.9

11.2

9.1

Last observation

7.1

13.2

Flood N = 18 Baseline

Last observation Earthquake N = 26 Baseline Last observation

Note. Also shown is Cohen’s dav ES (for within-subjects data), the 95% CI on d, and the percent superiority ES. CI = confidence interval, ES = effect size.

concern and with 12 of 18 cases showing reliable change (i.e., below the dashed-dotted line). The d ES is conventionally large (> 0.8; Lakens, 2013) and indicates that the mean difference is statistically significantly different pre to post. The PS ES also indicates a high probability of benefit post-treatment. In absolute terms, the d ES represents a reduction of 17.5 scale scores, sufficient to ensure that any client with a pretreatment score of ≤50 is below the likely PTSD threshold at the post-treatment observation (Funder & Ozer, 2019). Using the IES-R cutoff of 33, 75% of the massacre clients had probable PTSD before starting the treatment, but this dropped to 17%. This reduction in probable PTSD is consistent with what was observed following the earthquake and flood RCTs in the broad-spectrum conditions (change of 54–23% and 36–7%, respectively).

Among survivors of the earthquake, five participants showed little change in IES-R scores after consuming EMP+, but the majority showed clear benefit, with

Earthquake and Flood Trauma Results Figures 2a and 2b show comparable IES-R findings for, respectively, the participants in the Christchurch earthquake and the Alberta flood RCTs. As noted, for both of these studies, participants were predominantly women. At baseline, following the earthquake, the range of IES-R scores closely matched that of the massacre survivors, but the range of scores following the flood showed fewer cases reporting high IES-R scores, and here, the mean baseline IES-R score was two scale points below the cutoff for likely PTSD but above the threshold for clinical concern. However, for both sets of participants, the majority (all but two, in both studies) had baseline scores that were above the cutoff for clinical concern, and in the case of earthquake survivors, many were above the likely PTSD threshold. © 2021 Hogrefe Publishing

Figure 1. Mosque shooting IES-R scores at baseline and last observation for survivors (event in Christchurch, New Zealand, March 2019). The solid 45° diagonal line is the line of no effect, and the parallel dashed-dotted line shows the lower limit of the RCI. Vertical and horizontal dashed lines indicate the cutoff score for the threshold of clinical concern, and the solid horizontal and vertical lines mark the threshold for likely PTSD diagnosis. The Cohen’s d with its 95% CI in [ ] and the PS ESs are shown. The cross marks the means at the two time points. The last observation is that recorded for each client and at least 2 weeks since they began the micronutrients. ESs = effect sizes; IES-R = Impact of Event Scale – Revised; PS = percent superiority; PTSD = post-traumatic stress disorder; RCI = Reliable Change Index.

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Figure 2. (a) Earthquake IES-R scores at baseline and last observation for survivors (event in Christchurch, Aotearoa New Zealand, February 2011). The last observation was taken at the end of 4 weeks of consumption of eight EMP+ capsules per day. Other features are as for Figure 1. (b) Flood IES-R scores at baseline and last observation for survivors (event in Alberta, Canada, June 2013). The last observation was taken at the end of 4 weeks of consumption of four EMP+ capsules per day. Other features are as for Figure 1. IES-R = Impact of Event Scale – Revised; PS = percent superiority, PTSD = post-traumatic stress disorder.

reduction in most cases below the clinical concern threshold. Again, the ES was large (>0.8) and the mean change was statistically significant. As for the survivors of the massacre, based on the d ES, only those with scores >50 would not have been below the likely PTSD cutoff post-treatment. Again, the PS ES showed a high probability of treatment benefit. The pattern for the flood survivors was very similar. Only two cases showed no change over time; the rest showed a clear reduction in IESR scores to below the clinical concern threshold. The ES is again large (>0.8) and statistically significant, and the PS ES indicated a high likelihood of benefit. The majority of participants in both studies whose scores were above either clinical threshold at baseline reported change that was reliable.

Depression, Stress, and Anxiety Across All Three Disasters Figures 3a, 3b, and 3c show, respectively, the data for the DASS scores (separately for each subscale, viz. Depression, Anxiety, and Stress) for the survivors of the mass shooting and the participants in the postearthquake and postflood RCTs. For the mosque clients, the pattern observed in their IES-R scores was also evident in their DASS scores,

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especially for the Depression and Stress subscales, namely, one group who were clearly below the clinical cutoff at baseline (the low distress group) and a second group who were above the respective cutoffs. The range of scores at baseline across the subscales was also large, with individuals scoring from zero to the maximum or close to it. The mean scores for Depression, Anxiety, and Stress were well above the respective clinical cutoff scores indicating at least mild distress. At the last observation reported, for the Depression and Anxiety subscales, one individual in the low distress group showed a small (Depression) to moderate (Anxiety) increase in score. The balance of clients in this group showed little change. However, for most of the rest of the clients, large reductions in depression, anxiety, and stress were evident, with only two clients not demonstrating some reduction in scores, and with only one client reporting an increase in stress. At last observation, the majority reported DASS scores below the mild symptom cutoff score. The PS ESs (79–82%) confirmed a high probability of benefit, and the d ES were again all large (at close to 1) and statistically significant. The pattern of findings on the DASS subscales for the participants in the earthquake and flood RCTs resembles each other and the massacre data. Levels of depression and stress were higher than for anxiety, but baseline mean scores for all three subscales were above the clinical

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Figure 3. DASS scores shown, respectively, for depression (top panel), anxiety (middle panel), and stress (bottom panel) for mosque shooting clients (a), and earthquake (b) and flood (c) participants. Other features are as for Figures 1 and 2. DASS = Depression Anxiety Stress Scales; PS = percent superiority.

cutoffs for both disaster groups. Five (of 26) individuals in the earthquake RCT reported higher depression scores post-treatment, and two reported more stress. Otherwise, the pattern for participants in both RCTs and across all the DASS measures was for clear reduction in scores posttreatment, with post-treatment means being below the cutoff. The d ESs were all large (only slightly so for earthquake Depression and Anxiety) and statistically significant. The d ESs were consistently larger for the flood than for the earthquake RCT data, reflecting the lower variability in scores for this group. The PS ESs ranged from 77.5% to 88%, again indicating a high likelihood of benefit. Across the three events, the majority of individuals whose

baseline scores were above the respective clinical cutoffs showed reliable reduction in levels of distress posttreatment.

Consistency of Response in Mosque Clients How consistent were the changes observed across the measured domains of psychological distress for those surviving the massacre? Of the six clients who had low scores on the IES-R at initial presentation, only one initially had slightly elevated depression, anxiety and stress scores close to or slightly above the mild clinical cutoffs for the

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DASS. Of the 18 clients who were above the IES-R threshold for likely PTSD, only one displayed a (large) increase in this measure. Of the remaining 17 clients, all of whom showed a reduction in their IES-R scores with treatment, all but two of these clients showed decreases in their psychological symptoms across the four measures.

Classification as “Responders” Using the M-CGI The M-CGI-I (stress) identified 58% of clients affected by the massacre as “responders” to the treatment (i.e., they self-reported as “much” to “very much” improved). This percentage was again in line with those reported in the earthquake (42%) and the flood (57%) RCTs. It was noted for many clients across all three studies that sleep, irritability, and energy also improved as a result of the intervention. Figure 4 compares the number of responders across the three events, including the active comparator groups from the earthquake and stress studies: B vitamin, treatment-as-usual (TAU), and vitamin D.

Discussion Translation of knowledge gained from prior controlled research into the clinical work undertaken in the immediate aftermath of the mosque shooting provided evidence that broad-spectrum micronutrients contributed to

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reducing psychological distress and risk of PTSD, at least in the short term, for massacre survivors who elected to seek this treatment. There are clear methodological limitations arising from the clinical service nature of the work, as is true of any application of research to practice, notably the lack of any control condition or tight control over the dose and duration of treatment. Despite this, these findings are notable because this study was a third replication reporting benefit from micronutrient treatment postdisaster but, as a replication, was a study of a very different kind of disaster (human vs. natural), with males in the majority, and with clients who were largely from an immigrant and refugee community and members of a religious minority (in Aotearoa New Zealand). It also provides a demonstration of translational science in the context of a very traumatic event, and one where cultural factors required care in how the affected community was approached and offered a clinical service based on novel research findings. The inaugural studies followed the natural disasters of an earthquake (Rucklidge & Blampied, 2011; Rucklidge et al., 2012) and a flood (Kaplan, Rucklidge, Romijn, & Dolph, 2015), each of which badly affected a city and its adjacent region, in two developed countries (Aotearoa New Zealand and Canada). The circumstances under which these studies were conducted permitted methodologically sound research, particularly RCTs, although there were limitations, as might be expected of research in the aftermath of disaster, including only modest Ns, few male participants, and a relatively homogenous ethnicity among participants. Yet, despite these limitations, the

Figure 4. Percent responders (based on M-CGI-I stress) over earthquake, flood, and massacre studies. M-CGI-I = Modified Clinical Global Impression Improvement, responders identified based on self-reports of being much to very much improved.

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research showed that survivors of these events who consumed micronutrient supplements reported improved mental health relative to TAU or an active comparator treatment (vitamin D), notably reductions in depression, anxiety, and stress, and a clearly reduced risk of PTSD. The research also showed micronutrients to be as good if not more effective than an active control previously shown to be better than placebo (B vitamins) in managing stress. Following the earthquake, these benefits of micronutrients were still evident at a 1-year follow-up (Rucklidge, Blampied et al., 2014). The reanalysis of the RCT data presented here permits a systematic comparison of findings across the three replications of micronutrient treatment postdisaster, and the similarities in the findings across the three replications were striking. Of particular note were the IES-R d ES of 1.13 (massacre), 1.1 (earthquake), and 1.2 (flood) and the high likelihood of reduced scores after treatment (>80%). Replication is increasingly recognized as critical to progress in science generally (Cohen, 1990; Cumming, 2012; Schmidt, 2009) and in clinical science particularly (Tackett et al., 2019). Demonstrations of close and systematic replication of the effect of a class of treatments across diverse clients and situations provide compelling scientific evidence that there is a reliable phenomenon at work (Haig, 2014), and this is provided here. Furthermore, our conclusion regarding the benefits of micronutrients in reducing stress within disaster environments is strengthened by the placebo-controlled research showing superiority of micronutrients (specifically B vitamins) over placebo in also reducing stress (Young et al., 2019) as well as improving other psychological problems such as autism, aggression, and Attention-Deficit/Hyperactivity Disorder (ADHD; Adams et al., 2011; Gesch et al., 2002; Rucklidge et al., 2018; Rucklidge, Frampton, et al., 2014). One reason why nutritional supplementation is acceptable to communities affected by disasters is because the message to clients can be simple and couched in terms of the triage theory (McCann & Ames, 2009). Clients resonated with the narrative explaining that the body has limited resources and when survival is threatened, resources become diverted to the flight/ flight response, leaving the body nutritionally underresourced for other functions to continue unaffected. This narrative is nonthreatening and presents the struggle with anxiety and stress as a normal physiological reaction to a horrific event. It also identifies an important but neglected component – nutrition – for building personal resilience in a time of great stress. These lessons could now be extended to current stressors associated with the worldwide COVID-19 pandemic, an event that has already been identified as causing mental health challenges (Galea et al., 2020). © 2021 Hogrefe Publishing

From the perspective of a health system dealing with the aftermath of a disaster, the use of a simple intervention that does not require a large specialized workforce to implement, is easy to extend in space and time as required, and has immediate benefits for most consumers and few side effects holds enormous value. There is also a potential long-term cost saving, especially if early provision of micronutrients can permanently divert at-risk individuals from trajectories of distress that lead to PTSD or other major mental health disorders. The current (2020) cost of a month supply of Optimal Balance at the recommended dose is US $45, which could almost certainly be reduced by government procurement. We are not aware of any other treatment that can be supplied simply, can provide relief quickly, has few side effects, and has demonstrated replicability across countries and traumas. Psychologists involved in postdisaster assistance (Williams et al., 2007) need to be aware of the potential use of broad-spectrum nutritional supplements, not only as first-line treatments in their own right, but also as potentially beneficial adjunct treatments for psychotherapy. The data reported here also show that, for all the disasters documented, there were individuals who did not respond to the micronutrients. Taking nutritional supplements alongside medications has its own unique challenges (Popper et al., 2017), and the challenge of meeting the treatment needs of the individuals who did not respond must not be overlooked. This requires urgent research. It would also be useful to identify the mechanism by which the nutrients exert their effects, within the framework of triage theory or otherwise. Other research has identified that the nutrients increase diversity of the microbiome (Stevens et al., 2019) as well as show small epigenetic effects in terms of increased methylation (Stevens et al., 2018); however, biomarkers could usefully be collected before and after exposure to the nutrients/ placebo under stressful situations to better understand the impact that the nutrients may have on cortisol response. Based on the Chambless and Hollon (1998) criteria for a well-established treatment of at least two good betweengroup design experiments demonstrating efficacy, either superiority to placebo or equivalence to an already established treatment, there is now sufficient, cumulative evidence that internationally health systems could provide micronutrients as a treatment option for stress after traumatic community events. We urge health system leaders to accept scientific evidence of the kind reported here and implement the findings constructively. This would ensure that the next time any community is affected by a natural or other disaster (as is inevitable), those who suffer in the aftermath are provided with evidence-based best practice to reduce psychological injuries. This will benefit everybody – those directly affected, the wider International Perspectives in Psychology (2021), 10(1), 39–54

community, health personnel and other services, and the taxpayers and governments who must fund services in the aftermath of a disaster.

Electronic Supplementary Material The electronic supplementary material is available with the online version of the article at https://doi.org/ 10.1027/2157-3891/a000003 ESM 1. The file contains detail of the clinical service work.

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Conflict of Interest We have no conflicts of interest to declare. Authorship Julia Rucklidge: Director of the Mental Health & Nutrition Laboratory, University of Canterbury, led the postearthquake research, organized the supply of micronutrients following the mosque shootings, and coordinated the clinical service. Usman Afzali: A PhD student in psychology who acted as senior liaison with the mosque community in the provision of the micronutrients. We have included his story of participation as Electronic Supplementary Material (ESM 1). Bonnie Kaplan: Led the postflood research at the University of Calgary following the flooding in Alberta. Oindrila Bhattacharya: A doctoral student who assisted Usman Afzali in liaison with the mosque community. Meredith Blampied: A clinical psychologist and PhD student in the Mental Health & Nutrition Laboratory who assisted with clinical supervision of the treatment service to the mosque community. Roger Mulder: A psychiatrist who provided medical guidance and supervision for the clinical service. Neville Blampied: A member of the Mental Health & Nutrition Laboratory team who was involved with the postearthquake research and who did the data analyses and reanalyses reported and wrote the initial draft of the paper. Author Note The earthquake and flood data have been previously published in a different form in Kaplan, Rucklidge, Romijn, and Dolph (2015) and Rucklidge et al. (2012). The mosque shooting data have been presented at three conferences as part of keynote presentations: (1) Rucklidge, J. J. (2019, June 6). Challenges of translation of research to practice: Case example of community trauma [Conference session]. Lifestyle Medicine, Auckland, New Zealand; (2) Rucklidge, J. J. (2019, October 22). Innovation to disruption: The next steps in reducing the burden of mental illness [Conference session]. International Society of Research in Nutritional Psychiatry, London, UK; (3) Rucklidge, J. J. (2020, March 8). Latest research on nutrition for mental health [Conference session]. Australasian Integrative Medicine Association, Auckland, New Zealand. ORCID Julia J. Rucklidge  http://orcid.org/0000-0003-3793-7342 M. Usman Afzali  http://orcid.org/0000-0001-5119-9388 Bonnie J. Kaplan  http://orcid.org/0000-0003-1911-0472 Oindrila Bhattacharya  http://orcid.org/0000-0003-4421-4759 F. Meredith Blampied  http://orcid.org/0000-0002-8869-1971 Roger T. Mulder  http://orcid.org/0000-0002-8147-5838 Neville M. Blampied  http://orcid.org/0000-0002-0158-4904 Julia J. Rucklidge School of Psychology, Speech and Hearing University of Canterbury Private Bag 4800 Christchurch New Zealand julia.rucklidge@canterbury.ac.nz

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Policy Brief

Syrian Refugee Access to and Quality of Healthcare in Turkey A Call to Streamline and Simplify the Process En Chi Chen Global Health, McMaster University, Hamilton, ON, Canada Abstract. Although Turkey affirms the right to health regardless of citizenship status, as defined by the Declaration of Human Rights, there are gaps in the legislation and administration regarding the conditions for which an individual must fulfill as a Syrian refugee to access healthcare in Turkey (Mardin, 2017). One of the greatest healthcare access barriers is not gaining status under the temporary protection regulation (TPR) as a Syrian refugee (Mardin, 2017). Even after gaining status under the TPR, individuals are bound to the city in which they have registered and are designated, outside of which they are ineligible for healthcare (Mardin, 2017). This limits the autonomy of the individual when making appropriate resettlement decisions within Turkey. This process also poses an additional burden on healthcare professionals to act as healthcare access “gatekeeper” (Mardin, 2017). This policy brief seeks to outline both the challenges Syrian refugees face in accessing quality healthcare in Turkey and provide reformation suggestions to allow for a more streamlined approach. Furthermore, suggestions are made with consideration of lessening the burden of Turkey’s healthcare system as the host country. Keywords: policy brief, refugee, Turkey, Syria, healthcare, access, quality Impact and Implications. The failure to effectively respond to the Syrian refugee crisis in Turkey has left thousands of individuals without access to quality healthcare and continues to burden the health and administrative system in Turkey. It is critical for health systems in host countries like Turkey to respond to the needs of vulnerable individuals by providing comprehensive care while considering their other resettlement needs. By identifying areas of improvement to streamline and simplify Turkey’s healthcare response, the recommendations could enhance the well-being of Syrian refugees. Furthermore, this model could be applied to other host countries to better accommodate and care for displaced individuals around the globe.

Since the beginning of the Syrian refugee crisis, over 3.6 million Syrian refugees have fled to Turkey (WHO, 2018). Turkey currently hosts 60% of all Syrian refugees, and the number of refugees is only exponentially increasing (WHO, 2018). To obtain the Temporary Protection status as a Syrian refugee, individuals must first gain refugee status under the United Nations High Commissioner for Refugees (UNHCR) or an associated government entity (WHO, 2018). Garnering this status allows the individual to access legal rights and social services such as healthcare, education, and a work permit within Turkey (Assi et al., 2019). Syrian refugees are exposed to a myriad of risk factors that influence their health and their ability to access the healthcare system. Some of these health risks are directly related to forced migration such as “unhealthy living and working conditions, decreased levels of health literacy, and social exclusion and discrimination” (Cloeters & Osseiran, 2019). Other health concerns may have resulted from war-related traumas, injuries, or mental illnesses (Cloeters & Osseiran, 2019).

Furthermore, the prevalence of pre-existing chronic illnesses is often exacerbated in the displacement process due to various factors. Individuals who have experienced chronic stress, as is often the case for refugees, are more prone to high blood pressure, diabetes, and cardiovascular health challenges, compounded in severity by the lack of consistent care as well as inadequate lifestyle conditions for illness management (Cloeters & Osseiran, 2019). As the number of refugees continues to increase, there is a continual backlog of individuals who are waiting to be registered under the temporary protection regulation (TPR). During this wait, individuals do not have access to healthcare. This policy brief seeks to address this urgent issue by first identifying the specific challenges from both the perspective of the Syrian refugees and the host country, Turkey. Following this, recommendations are made to inform policy reformation to specifically address these challenges with the aim to streamline and simplify the process of gaining access to healthcare for Syrian refugees in Turkey.

International Perspectives in Psychology (2021), 10(1), 55–57 https://doi.org/10.1027/2157-3891/a000005

E. C. Chen, Syrian Refugee Access to and Quality of Healthcare in Turkey

Current Approach and Challenges For Syrian refugees to access healthcare in Turkey, they must obtain Temporary Protection Identification Documents under the TPR, formally instated in October 2014. Under Turkish domestic law, the status of a refugee is regulated by the Law of Foreigners and International Protection of 2013. Under this regulation, individuals are designated into categories of “convention refugees,” “conditional refugees,” and “person under temporary protection” (Cantekin, 2019). For the purpose of this policy brief, the focus will be on individuals under “person under temporary protection.” These individuals are not eligible for convention refugee status but are compelled to leave their country of origin and are seeking “urgent and temporary” asylum in Turkey within the context of a mass population movement (Cantekin, 2019). Because of the vast number of asylum seekers in Turkey from Syria, the government has designated several provincial public services outside of camps to provide care for these individuals (Cantekin, 2019). Under the article 33(2)(a) of the TPR, persons under temporary protection are required to stay in the province under which they were registered and would only be eligible for social services, including healthcare, in their designated regions (Cantekin, 2019). A summary of the challenges Syrian refugees face in the process of accessing healthcare as well as challenges Turkey faces as a host country are provided in the next two sections.

Challenges Faced by Syrian Refugees There are many challenges that Syrian refugees face in trying to access healthcare upon arrival in Turkey. The first of which revolves around obtaining TPR status. The criteria for obtaining the TPR identification card require first that individuals are registered as a refugee as defined by the UNHCR. This process can often take a significant amount of time (WHO, 2018). Prior to the provision of the TPR identification, Syrian refugees have no legal status and therefore, have no access to healthcare and other social services within the host country. Once the individual obtains a TPR, there are further bottlenecks to the process of accessing healthcare such as having to make an appointment either online or directly with a primary healthcare provider in person. These processes present accessibility challenges for those without appropriate technology or internet or who are unable to physically access the appointment center (Alawa et al., 2019). The processing speed for TPR status registration is based on the volume of refugees entering the country at a given time. In the case of an influx of newly displaced individuals, unregistered individuals can go a significant amount International Perspectives in Psychology (2021), 10(1), 55–57

of time (up to months) without having access to any health and social services. This could be detrimental to their individual and collective health outcomes (Cloeters & Osseiran, 2019). Based on a needs assessment by the Yuva Association in Turkey, 13% of refugees were not registered under the TPR (Cloeters & Osseiran, 2019). These individuals do not receive coverage on prescription medication or other rehabilitative services such as physiotherapy (Cloeters & Osseiran, 2019). This serves as another roadblock to treatment follow-through and the long-term health of these individuals which can be compounded with other challenges of displacement such as crowding, poor living conditions, and lack of sanitation (Saleh et al., 2018).

Challenges Faced by Turkey as the Host Country Healthcare professionals are acting as gatekeepers for refugees’ movement and mobility within the country as they dictate who is within their “registered location,” and thus, eligible for healthcare, and who is not (Mardin, 2017). This compromises their ability to provide unbiased and objective care to patients as they may be compelled to give care those who might not qualify under their region of responsibility. In addition, this places strain on their working time as they are burdened with this added administrative task rather than the task of medical care. Another challenge Turkey may face is being unprepared for the influx of refugees due to a lack of healthcare infrastructure available to care for the individuals as well as understaffing of healthcare professionals. The plans and processes to expand refugee healthcare centers throughout Turkey is a slow and costly process with no intermediate, temporary solutions (WHO UNHCR, 1997). Furthermore, healthcare professionals often feel inadequately trained to treat complex health challenges experienced by refugees. Berthold et al. (2014) explored some of these complexities by examining the often comorbid mental and physical health problems that refugees experience due to displacement related traumas. They found that various physical illnesses could not be treated easily due to their significant correlation to mental illnesses. In addition, mental health and rehabilitation services for Syrian refugees were found to be weak due to an inadequate number of qualified healthcare professionals in Turkey (Assi et al., 2019). Healthcare professionals in host countries such as Turkey may experience burnout due to not being equipped to meet the needs and demand of their patient population (Cloeters & Osseiran, 2019). On a broader level, there is a general lack of coordination among civil society organizations and healthcare organizations within Turkey leading to redundancy in efforts and © 2021 Hogrefe Publishing

E. C. Chen, Syrian Refugee Access to and Quality of Healthcare in Turkey

inefficient allocation of resources. There is no overarching governance to provide better management of pooled resources (Cloeters & Osseiran, 2019). Furthermore, patient healthcare information is inconsistently recorded between regions, which hinders the process of transitioning toward nation-wide, portable care, further reducing the gaps in healthcare provision for vulnerable populations.

Policy Recommendations Responding to Challenges Faced by Syrian Refugees To reduce the barriers associated with access to healthcare experienced by Syrian refugees in Turkey, there should be a focus on streamlining and simplifying the process. First, there should be a simpler and faster way of designating TPR status. Upon arrival, an individual claiming refugee status, regardless of their status with the UNHCR, should receive a TPR identification immediately. Furthermore, upon receiving the TPR identification, individuals should be able to access nation-wide healthcare rather than just in the region of registration. This will allow for greater individual autonomy regarding relocation decisions within the country. To address the challenges associated with navigating the system, the healthcare administration should consist of individuals who share the same language as Syrian refugees and are equipped to assist them in accessing the care they need.

Responding to the Challenges Faced by the Host Nation, Turkey The healthcare administration and healthcare professional teams should consist of Syrian individuals. This serves a two-pronged purpose of encouraging both the integration of displaced professionals and increasing the quality of care experienced by Syrian refugees who may be more comfortable receiving service from healthcare professionals who share similar language and cultural understandings. These efforts will also benefit the host country by remediating the current understaffed healthcare centers. To increase the quality of care for Syrian refugees and to concurrently support Turkish healthcare professionals and their well-being, Turkish healthcare professionals should receive specific training on how to treat and manage complex health needs of their patient population. Finally, to address the challenge of a lack of coordination among civil society organization efforts, a common database should be adopted at all registration and healthcare centers. This will © 2021 Hogrefe Publishing

allow for easier transition into nation-wide care reforms, which will allow individuals to access quality healthcare no matter their geographical location within Turkey.

References Alawa, J., Zarei, P., & Khoshnood, K. (2019). Evaluating the provision of health services and barriers to treatment for chronic diseases among Syrian refugees in Turkey: A review of literature and stakeholder interviews. International Journal of Environmental Research and Public Health, 16(15), 2660. https://doi.org/10. 3390/ijerph16152660 Assi, R., Özger-İlhan, S., & İlhan, M. N. (2019). Health needs and access to health care: The case of Syrian refugees in Turkey. Public Health, 172, 146–152. https://doi.org/10.1016/j.puhe.2019. 05.004 Berthold, S. M., Kong, S., Mollica, R. F., Kuoch, T., Scully, M., & Franke, T. (2014). Comorbid mental and physical health and health access in Cambodian refugees in the US. Journal of Community Health, 39(6), 1045–1052. https://doi.org/10.1007/ s10900-014-9861-7 Cantekin, D. (2019). Syrian refugees living on the edge: Policy and practice implications for mental health and psychosocial wellbeing. International Migration, 57(2), 200–220. https://doi.org/ 10.1111/imig.12508 Cloeters, G., & Osseiran, S. (2019). Healthcare access for Syrian refugees in Istanbul: A gender-sensitive perspective workshop report. Istanbul Policy Cluster, Sabanci University. Mardin, D. F. (2017). Right to health and access to health services for Syrian refugees in Turkey. MiReKoc Policy Brief Series. Koc University. https://doi.org/10.13140/RG.2.2.15199.36002 Saleh, A., Aydin, S., & Koçak, O. (2018). A comparative study of Syrian refugees in Turkey, Lebanon, and Jordan: Healthcare access and delivery. International Journal of Society Systems Science, 8(14), 448–464. https://doi.org/10.26466/opus.376351 WHO. (2018). Health emergency response to the crisis in the Syrian Arab Republic annual report 2018 (World Health Organization Regional Office for Europe). https://www.euro.who.int/en/ countries/turkey/publications/health-emergency-response-tothe-crisis-in-the-syrian-arab-republic-annual-report-2018-2019 WHO UNHCR. (1997). Social and economic impact of large refugee populations on host developing countries (Executive Committee of the High Commissioner’s Program Standing Committee). https://www.unhcr.org/uk/excom/standcom/3ae68d0e10/ History Received June 23, 2020 Revision received November 13, 2020 Accepted January 2, 2021 Published online February 17, 2021 ORCID En Chi Chen  https://orcid.org/0000-0002-8516-739X En Chi Chen Global Health McMaster University 1280 Main Street W Hamilton, ON L8S 4L8 Canada angelachen110@shaw.ca

International Perspectives in Psychology (2021), 10(1), 55–57

Instructions to Authors International Perspectives in Psychology® is committed to publishing research that examines human behavior and experiences around the globe from a psychological perspective. It publishes intervention strategies that use psychological science to improve the lives of people around the world. The journal promotes the use of psychological science that is contextually informed, culturally inclusive, and dedicated to serving the public interest. The world’s problems are imbedded in economic, environmental, political, and social contexts. International Perspectives in Psychology® incorporates empirical findings from education, medicine, political science, public health, psychology, sociology, gender and ethnic studies, and related disciplines. Consistent with Division 52’s core mission, vision, and values, International Perspectives in Psychology® encourages authors who are submitting papers for peer review to work internationally and collaboratively, for example by including authors from more than one country, and especially from outside the US. International Perspectives in Psychology® publishes the following types of articles: Articles and Policy Briefs. Manuscript submission: All manuscripts should in the first instance be submitted electronically at http://www.editorialmanager.com/ips. Detailed instructions to authors are provided at www.hgf.io/ipp. Copyright Agreement: By submitting an article, the author confirms and guarantees on behalf of him-/herself and any coauthors that the manuscript has not been submitted or published elsewhere, and that he or she holds all copyright in and titles to the submitted contribution, including any figures, photographs, line drawings, plans, maps, sketches, tables, and electronic supplementary material, and that the article and its contents do not infringe in any way on the rights of third parties. ESM will be published online as received from the author(s) without any conversion, testing, or reformatting. They will not be checked for typographical errors or functionality. The author indemnifies and holds harmless the publisher from any third-party claims. The author agrees, upon acceptance of the article for publication, to transfer to the publisher the exclusive right to reproduce and distribute the article and its contents, both physically and in nonphysical, electronic, or other form, in the journal to which it has been submitted and in other independent publications, with no limitations on the number of copies or on the form or the extent of distribution. These

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January 2021

Working Toward Sustainable Development for All Suman Verma / Anne C. Petersen / Jennifer E. Lansford (Editors)

Sustainable Human Development Challenges and Solutions for Implementing the United Nations’ Goals Zeitschrift für Psychologie, vol. 227/2 2019, iv / 72 pp., large format US $49.00 / € 34.95 ISBN 978-0-88937-556-7 In September 2015, 193 member states of the United Nations adopted the action plan Transforming Our World: The 2030 Agenda for Sustainable Development, which outlines 17 Sustainable Development Goals (SDGs). The Agenda recognizes the need to look beyond narrow economic measures of progress and consider all aspects of well-being for current and future generations, to eradicate poverty worldwide, and to safeguard the planet. This collection of research from around the world shows that the SDGs need to be addressed in a holistic manner and that psychologists Contents and topics include • Working Toward Sustainable Development for All • The Role of Psychology in Addressing Worldwide Challenges of Poverty and Gender Inequality • Adaptation and Application of the Measuring Early Learning Quality and Outcomes (MELQO) Framework to Early Childhood Education Settings in Columbia

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play an important role in their effective implementation, having expertise in addressing questions of how to make national policies work for diverse individuals, how to work with vulnerable persons, and how to track individuals’ development over time in the face of societal changes. In particular, the importance of investment in positive child and youth development, the role of life span theories, and the use of longitudinal data are discussed in this volume. Three commentaries explore different aspects of the research presented and help us further understand the complexities of meeting the Agenda.

• Experiences of Community Youth Leaders in a Youth-Led Early Childhood Education Program in Rural Pakistan • Illuminating the Use of the Speciﬁcity Principle to Go Inside the Black Box of Programs

How to provide culturally sensitive care for clients with PTSD and related disorders “The field of cultural clinical psychology takes an important stride forward with this carefully edited volume on the cultural shaping of posttraumatic stress disorder.” Andrew G. Ryder, PhD, Associate Professor of Psychology, Concordia University, Montreal, QC, Canada

Andreas Maercker / Eva Heim / Laurence J. Kirmayer (Eds.)

Cultural Clinical Psychology and PTSD 2019, x + 236 pp. US $62.00 / € 49.95 ISBN 978-0-88937-497-3 Also available as eBook

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This book, written and edited by leading experts from around the world, looks critically at how culture impacts on the way posttraumatic stress disorder (PTSD) and related disorders are diagnosed and treated. There have been important advances in clinical treatment and research on PTSD, partly as a result of researchers and clinicians increasingly taking into account how “culture matters.”

• How culture shapes mental health and recovery

For mental health professionals who strive to respond to the needs of people from diverse cultures who have experienced traumatic events, this book is invaluable. It presents recent research and practical approaches on key topics, including:

Providing new theoretical insights as well as practical advice, it will be of interest to clinical psychologists, psychiatrists, and other health professionals, as well as researchers and students engaged with mental health issues, both globally and locally.

• How to integrate culture and context into PTSD theory • How trauma-related distress is experienced and expressed in different cultures, reﬂecting local values, idioms, and metaphors • How to integrate cultural dimensions into psychological interventions