Cultural Stress Revisited

Hastings K Shula Aizhong Liu

Cultural Stress Revisited

Hastings K Shula Aizhong Liu*

Cultural stress is no longer a rare phenomenon because the world has been reduced to the size of a village due to modern technology and advancements.It is a concept that grows in magnitude each year.More and more people are affected.In this paper，we discuss the assessment of cultural stress by combining some instruments like the Perceived Stress Scale，the Depression Anxiety，and Stress Scale with the Cultural Stress Scale.They appear to be valid and can be used across different cultures.We discuss the need to come up with a standard instrument for measuring cultural stress as opposed to having so many.We also outline ways of coping with cultural stress as it occurs at different stages.There is need for more research to counter the negative effects of cultural stress.

Cultural stress;Sojourner;People at risk;Coping mechanisms

Cultural stress/shock is“that feeling”one experiences as one immerses oneself into a culture alien to his［1］.The deeper he goes，the more acute the feeling.From the very time man started exploring his surroundings he became aware of cultural differences.The concept of“Culture Shock”was introduced by Oberg in 1954，when he mentioned the complications that arise with living in a new cultural environment.These complications arise because of the differences in social behaviors，beliefs and expectations exhibited by different cultures［2-4］.In this paper，we review the assessment of cultural stress，and how to cope with it.

Assessment of cultural stress:

This is a topic that continues to raise a lot of debate.It seems that a lot of instruments have been developed by many researchers to measure cultural stress.There has not been a specific instrument that stands out as the standard.We believe this can be attributed to the fact that during research，specific information is often targeted，requiring specific instruments［5］.Because the field is wide，no single instrument has been able to capture all the information needed.Furthermore，research directions are always changing.The need to develop culture-specific instruments may be another reason.Usually，these instruments are combined with other instruments whose sole purpose is to indicate or suggest the existence of stress in an individual.Once this is established，the cultural stress scale’s use is to confirm whether the stress is indeed cultural.

Perhaps one instrument that stands out is the Acculturative Stress Scale for International Students(ASSIS)，developed by Sandhu and Asrabadi in 1994［6］.Its world-wide use we believe stems from the ever-increasing need to look into the experiences of International students，being one of the largest groups of sojourners.The ASSIS is a 36-items Likert type 5-point scale with responses ranging from“Strongly disagree”to“Strongly agree”.The total score ranges between 36 and 180，the higher the score，the higher the stress.It is divided into 7 factors i.e.:Perceived discrimination，Homesickness，Perceived hate，F(xiàn)ear，Stress due to change/Culture shock，Guilt and Nonspecific.It has also been modified as the Acculturative Stressor Scale forChinese Students(ASSCS) to suitChinese students’cultural background.The Sociocultural AdjustmentScale (SCAS) developed by Black in 1988［7］，is a 14-item Likert type 7-point scale with responses ranging from“Very unadjusted”to“Completely adjusted”.It was developed to suit business expatriates.Another version of the SCAS suitable for students is a 29-item likert type 5-point scale with options ranging from “Extreme difficulty”to“No difficulty”，which wasdeveloped byWard and Kennedyin 1999［8］.These instruments are easily modifiable according to the needs of various researchers.We feel this leads to the possibility of most of these scales losing their psychometric properties and validity.

Another scale of note is the Cultural Stress Scale(CSS)developed by Thomson，Rosenthal and Russell in 2006［9］，when they measured for cultural stress among international students at an Australian university.It is an 8-item Likert type 4-point scale which measures students’perception of difficulties experienced as they live away from home，with responses ranging from“Not at all”to“Very much”.We believe the scale is quite easy to administer and difficult to be misunderstood by students.The developers reported a satisfactory internal reliability(alpha=0.75)for the scale during their study.Good as this may sound;we are of the view that the scale should be tested in a different cultural environment，for example，in Asia or Africa，to determine its consistency cross culturally.It appears that the scale cannot stand alone as an indicator of the presence of stress;hence the need to support it with stress-specific instruments like the Perceived Stress Scale(PSS)or the Depression，Anxiety and stress scale(DASS)and many others.

The PSS is purported to be one of the most widely used instrumentsin measuring the perception of stress［10］.Another scale that appears to have an increasing audience and use is the DASS.The Holmes and Rahe Stress Scale(also known as the Social Readjustment rating Scale-SRRS)is another instrument used to assess the presence or absence of stress in an individual［11］.It must be said however that most of these instruments indicate the individual’s perception，and are not based on clinical evidence.Moreover，Hurst et al suggested that most of these life change inventories have poor psychometrics.

For the purpose of this review，we will look at two instruments i.e.;the PSS and the DASS.The PSS is attributed to Cohen et al，1983［12］.It is claimed that the PSS is the only empirically established index of general stress appraisal.According to its developers，the PSS measures the respondent’s perception of a situation as being stressful.They say the PSS is not a diagnostic instrument，so there are no cut-offs，but only comparisons between people in one’s own sample.There are three versions of the PSS i.e.;the 4，10 and 14-item scales.They have all been said to have high psychometric properties.The scale is a Likert type scale which asks the respondent about his feelings and thoughts during the past month.It has four possible responses ranging from，“never”to“very often”.According to the developers，the PSS scores may be obtained by reversing responses to the four positively stated items-4，5，7 and 8，and then summing across all scale items.Higher scores indicate higher levels of perceived stress and vice versa.The PSS can be administered on-line without its psychometric properties being affected［10］.

The DASS is a set of three self-reporting scales developed by Lovibond and Lovibond in 1995，and was designed to measure the three negative emotions of depression，anxiety and stress.Each of the three DASS scales contains 14 items，divided into subscales of 2-5 items with similar content.A 4-point Likert type scale with 42 items is used to determine the extent of the respondent’s experience of each state during the past week.There are four possible responses ranging from“Did not apply to me at all”to“Applied to me very much，or most of the time”.The shorter 21-item scale is preferred in research because it takes a shorter time to complete.The DASS is said to have properties that allows it to distinguish among the three emotions of depression，anxiety and stress，and assess their degrees of severity.The scores for each emotion are summed and compared to the recommended cut-offs.For the 21-item scale，the final score should be doubled to equate it to the scores one would obtain if he had used the 42 items scale.Even though the DASS is said to be userfriendly to both researchers and clinicians and is easily administered by non-psychologists，the interpretation and decisions based on results must be made by an experienced clinician in combination with other forms of assessment.

While the PSS is claimed to be one of the most used in measuring the perception of stress，we believe its reference to events during a period of one month makes it susceptible to the respondent’s current state of mind.On the other hand，the DASS measures the emotions on a week’s experience of the subject.The DASS has the advantage of distinguishing among the subject’s emotional experiences.This allows it to determine whether in fact，the respondent is experiencing stress.It is possible to measure the three emotions at once as compared to the PSS which only measures stress.It is quite possible that a subject may be experiencing cultural-induced anxiety or depression.Its use in clinical settings is another plus for the DASS as a stress-measuring instrument.Although there are many instruments being used in the assessment of stress，the PSS and the DASS seem to be preferred by most researchers.We agree with the view that this is partly due to the fact that they are easily available on-line and at no cost.More importantly，they have both been validated and improved，and translated into many languages，making them both cross-culturally friendly.The DASS has been recommended for having very high psychometric properties in both clinical and normal adult samples［13-14］.Some researchers have also concluded that the PSS has satisfactory psychometric properties［15-16］.

People at risk:

Most researchers conclude that“Cross border travelers” i.e.;immigrants，refugees，expatriates，missionaries，businessmen，students，tourists are at highest risk to cultural stress experience.“Sojourner”(temporary resident)is the term frequently used to describe this vulnerable group.Refugees，forcibly uprooted from their natural surroundings，seem to have the highest levels of cultural stress followed by students and expatriates，respectively.Younger sojourners appear to be more affected than the older ones.The United Nations high commissioner for refugees(UNHCR)annual report indicated that there were more than 42 million refugees in 2009.Estimations are that from the USA alone there are almost 1.5 million students studying abroad at any time but Chinese students’numbers are even higher.The World Tourism Organization had projected that by the year 2010 the number of international tourist-related journeys will rise to a total of 940 million trips per year.These figures give a tip of the numbers of people at risk of experiencing cultural stress.

Sojourners from Eastern Europe and，Asia particularly，are said to be very prone to cultural stress［4，17-18］.One reason that stands out is the believed huge differences of Asian cultures to Western cultures.We believe Asians comprise the biggest number of sojourners worldwide and are therefore，the most researched on，hence the apparent high level of stress in comparison to other sojourners.Similar studies on sojourners in Eastern Europe and Asia may prove otherwise.Until recently，Asia was not among the top destinations for westerners.Today，China is the number seven top destination for American students.This turn of events will encourage cultural related research on these students which has been almost non-existent so far.Latin-Americans followed by the Africans also contribute a large number of sojourners，respectively.

Coping with cultural stress:

Usually，a sojourner experiencing cultural stress is irritable，ethnocentric，complains about the climate，food，refuses to learn the host language etc.Insomnia，hypersomnia and poor appetite are not uncommon［19］.This may lead to the sojourner’s premature return home if he fails to ride the“cultural stress wave”，categorized in stages that may occur one after another or overlap i.e.;honeymoon，hostility/distress，humorous/reintegration，and in-sync/autonomy［20-21］.It is crucial，therefore，that the sojourner be aware and prepare for cultural stress as it happens.

Well-before departure，the sojourner must search for information concerning his host-country’s culture，history，politics，geography，economy，important calendar events and places of interest.In our view，which is also shared by a number of researchers，pre-departure training and preparation of the sojourners by companies or authorities responsible for their welfare are key to a successful sojourning［22-25］.It is suggested that the sojourner should learn the language or at least some useful phrases of the host country to make it easier for him to get around.

In the first 4 weeks，everything is a novelty(honeymoon).The sojourner notices superficial tips of the“cultural iceberg”，i.e.:the food，dressing，music，which he finds intriguing.It is suggested that the sojourner quickly locate important landmarks like the bank，supermarket，church，hospital，schools，and communication facilities and get acquainted to the transport network.One must try to make friends with the locals and other foreigners as soon as possible［8］.Making the effort to speak the local language will lead to more local friends.Culture Stress manifests itself when one attempts to get every-day things done but realize the differences［26］.Feelings of loneliness or homesickness may set in，making the sojourner more vulnerable to stress.

It appears that no matter how well-prepared the sojourner is cultural stress almost always happens(hostility stage)，even to the most seasoned traveler.The sojourner must be wary of the situations that trigger the symptoms and develop measures to counteract them.Social support appears to be an effective stress-reduction conduit［27-29］although we advocate caution because multicultural environment brings together people with different views and ideas of accessing social support.One is advised to eat healthily and exercise regularly.For international students，it is advisable to find a hobby and join social clubs.According to some authors，sojourners must set realistic goals because this may also be a cause of stress if the goals are unattainable［30-31］.

Some sojourners are unable to cope with the stress and are perpetually cocooned in a negative world and reject the host culture and its people.If one is religious，contact with a faith community will put him in touch with a familiar setting，whether it is a church，mosque，synagogue or temple.We believe ethnocentricity fuels cultural stress.Recognizing that the local culture is a valid way of life，and learning to function in it by being flexible and adaptive is cardinal.Developing tolerance to what appears to be strange and accepting the ambiguities observed in the host culture is also important.It has also been suggested that it is sometimes necessary to develop a practice in order to fit in and discard it later when not needed［29，32］.If possible，keeping a diary to record one’s daily experiences as one traverse the local culture is a good stress-reducing technique.

After 6 to 12 months，the sojourner may be able to identify and correct mistakes and make light of past experiences and troubles(humorous stage).The feelings of culture shock，if experienced would no longer be as intense as perceived in the previous months.One starts to develop problem-solving skills for dealing with the culture，and begins to accept the culture ways with a positive attitude.One becomes concerned with basic living again，and things become normal at this point and one is able to develop real friendships with one’s hosts［4，33］.

The In-Sync stage is when the sojourner is completely adjusted to the host country，included in groups and discussions，with a social network，and understands the locals.All the things that used to stress him take on a new meaning because he can now understand why they happened.The sojourner is able to participate fully and comfortably in the host culture.Mastery does not mean total conversion to the host culture.Most people only adopt some aspects of the host culture that allows them to function optimally and comfortably.It is sometimes referred to as the biculturalism stage because the sojourner is thought of as having embraced two cultures i.e.;his and that of the host.He appreciates local humor and able to act as an advisor to the“newbies”.It appears that most sojourners do reach this stage of acculturation［34］.

International travel has become as easy as taking a walk in the garden，making the world into one small village with a vast culture concoction，bringing cultural stress to our door-steps.Epidemiological indicators must be made readily available to help monitor cultural stress trends.The DASS and the PSS appear to have satisfactory psychometric properties that make them ideal instruments for measuring cultural stress when combined with the CSS.However，there is need to develop an instrument that will be incorruptible when translated into other languages and used cross-culturally.It must be less subjective，user-friendly and easy to interpret and be able to stand the test of time.This will result in standardizing the assessment and diagnosis of cultural stress.It is important to remind ourselves that culture shock is entirely normal and most times，unavoidable.Inter-cultural education must be introduced in schools as a compulsory course for all students to educate them about other cultures.Our experience of cultural stress enhances our recognition and appreciation of other cultures.Valuable skills will be derived from it that will serve us in many ways now and in the future，skills which will be part of the benefits of being a sojourner.For most sojourners，culture shock is a mild，transitory annoyance that can be overcome with relative ease through personal effort and increased knowledge and with the assistance of sympathetic friends and advisers.The recovery from culture shock is the mirror image of its onset-that is，it comes on gradually and leaves the same way.

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*Corresponding author.Department of Epidemiology＆ Health Statistics，School of Public Health，Central South University，110.Xiangya Rd，Changsha，Hunan，PR China，410078.lazroy@live.cn