By: Daniel
L. Segal, Andrea June, and Meghan A. Marty
Culture refers to a common sense of beliefs, norms, and
values among a group of people. Culture impacts whether individuals seek help,
what type of help they seek, what types of coping styles and social support are
available, and how much stigma is attached to mental illness (US Department of Health
and Human Services (DHHS), 2001).
The main purposes of a diagnostic interview are to establish
a therapeutic relationship with the client and to begin to formulate
a clinical diagnosis. Failing to consider issues of diversity can negatively impact
both the relationship and the diagnosis, which can ultimately reduce the effectiveness
of psychotherapy.
Diversity, as it is discussed here, includes all aspects of cultural identity
such as age, gender, geographic location, physical ability, race and ethnicity,
religious preference, sexual orientation, and socioeconomic status. Consideration
of cultural issues is particularly important given the increasing diversity of the United
States and the likelihood of clinicians encountering clients from cultural
backgrounds different from their own, sometimes markedly so. Three major domains of cultural
competence are
(1) Awareness of one’s own assumptions, values, and biases,
(2) Understanding the worldview of culturally diverse clients,
and
(3) Knowledge of culturally appropriate intervention strategies and techniques (Sue
& Sue, 2008).
Next, we briefly touch upon each of these domains with the caveat
that this section provides a general overview of the issues and therefore is not
intended to provide the necessary background material for clinicians to adequately
assess clients from different cultural groups.
Impact of Diversity on the Therapeutic Relationship
As we have highlighted earlier, a good
working alliance is crucial for psychotherapy to be effective. Particularly
during the first few sessions, clinicians must create good rapport and establish their
credibility in a way that is sensitive to the client’s culture.
It is important to determine external factors related to the
presenting problem for clients who have suffered from discrimination such as racism
and sexism, in some cases for many years. Finally, assessing the positive assets of
culturally diverse clients, such as family, community resources, and religious
organizations is essential as well.
Dana (2002) describes a process by which African-American
clients may “size up” a mental health clinician, and suggests that African
Americans look for signs of genuineness, authenticity, and approachability in
mental health clinicians. Individuals from other racial or ethnic groups may find it
important to maintain formality with professional helpers.
The clinical and diagnostic interview is often a client’s
first experience
with the mental health-care system; therefore, it may be necessary to
spend time during the interview
exploring the client’s expectations regarding psychotherapy. For instance,
different meanings for the term clinician can
be found across different cultural groups, ranging from
physician, to medicine man/woman, to folk healer (Paniagua, 2005).
Understanding the client’s definition of clinician will enhance the clinician’s
ability to help the client manage his or her problem. The field of psychology can
function as a culture since it provides a lens for viewing the world. Clinicians
must be aware of the assumptions and biases of diagnosis and treatment in the practice
of traditional psychology.
Sue and Sue (2008) describe several
culture-bound values of psychology including: focus on the individual; preference for verbal, emotional,
behavioral expressiveness; insight; self-disclosure; scientific empiricism;
distinctions between mental and physical functioning; ambiguity; and patterns
of communication. Nonverbal communication, such as bodily movements (e.g., eye contact,
facial expression, posture), the use and perception of personal and interpersonal
space, and vocal cues (e.g., loudness of voice, pauses, rate, inflection) can vary
depending on cultural factors (Sue & Sue, 2008).
Clinicians should be aware of their own communication style
and anticipate how it may affect clients with a different communication
style. To facilitate rapport with clients of a different culture, it may be helpful for
clinicians to match the client’s rhythm and pace of speech, maximize awareness of their
comfort level with eye contact and physical distance, show respect for
hierarchy in the family and extended family, and use appropriate metaphors and symbols
(Ingram, 2006).
Adjustments can be made to the interview that may help to
increase the comfort level of the client and serve to strengthen the
therapeutic relationship. For example, clients with a visual impairment may require large
print questionnaires and informed consent forms. Alternatively, the clinician
could offer to read printed materials aloud. Hearing amplifiers can be offered to
those clients with a hearing impairment. Interpreters
can be used when the clinician and client do not share the same language. An interpreter
can help to facilitate a client’s sense of belonging at the treatment site, as well as
increase client trust in the clinician and the psychotherapeutic process (Paone
& Malott, 2008). Professional interpreters should have training in mental health. Due
to privacy and confidentiality concerns, use of a client’s family member as an
interpreter for psychotherapy is generally not recommended (Paone & Malott,
2008; Sue & Sue, 2008).
Modifications in the diagnostic interview may also include
clinicians being more flexible in their role and shifting the traditional
boundaries of “clinician.” For example, for a client who has difficulty getting to the mental
health clinic because of lack of transportation, the clinician may conduct the
interview outside of the office, such as in the client’s home or another
convenient location. Having a more active style by offering concrete advice and
assistance may be necessary, such as providing information on obtaining social services if
they are needed by the client. Consulting family members and paraprofessionals or
folk healers may be appropriate in some cases in order to better understand the
struggles of culturally diverse clients (Paniagua, 2005).
Impact of Diversity on Clinical Diagnosis
Clinicians must be sensitive to cultural
issues not only to more effectively establish a therapeutic relationship, but
also because of the impact of diversity on clinical diagnosis.
An accurate diagnosis is essential, as it facilitates
communication, dictates the nature of treatment, and provides an indication of the
likely prognosis and course of the disorder (Segal & Coolidge, 2001).
During the clinical interview, clinicians use the client’s description
of the frequency, intensity, and duration of the symptoms; signs from a mental
status examination; and the clinician’s own observations and judgment of the client’s
behavior to determine a formal diagnosis of a mental disorder. The final
diagnosis depends on the clinician’s belief about whether the client’s signs, symptom
patterns, and impairment of functioning meet criteria for a given diagnosis, as set forth
by the American Psychiatric Association (APA, 2000) in the Diagnostic
and Statistical Manual of Mental Disorders.
Although the symptoms of mental disorders are found
worldwide, diagnosis can be challenging because the manifestations of
mental disorders vary with age, gender, race, ethnicity, and culture (DHHS, 2001).
Culture can account for variation in the ways in which clients communicate
their symptoms, which symptoms they report, and the meanings they attach to mental
illness.
Clinicians who are unfamiliar with a client’s frame of reference may
incorrectly diagnose as psychopathology variations in behavior, belief, or
experience that are particular to and normative within the client’s culture. For example,
speaking in tongues, hearing the voice of God, or witnessing spiritual beings
should probably not be considered pathological for individuals from certain
religious communities, whereas it may be considered a problem from someone who is
nonreligious (Johnson & Friedman, 2008). Some
have suggested that the use of structured and semi-structured interviews can
reduce clinician bias with regard to diagnosis (Aklin & Turner, 2006).
The most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV-TR;
APA, 2000) provides an outline designed to assist clinicians with developing a
culturally appropriate clinical formulation. Clinicians are encouraged to explore and
provide a narrative summary for each of five categories, which include:
1. Cultural identity of
the client: ethnic or cultural reference groups, degree of involvement with both culture
of origin and host culture, language abilities, use, and preference.
2. Cultural explanations
of the client’s illness: predominant idioms of distress, meaning and perceived severity
of symptoms in relation to norms of cultural group, local illness category
used to identify the condition, perceived causes of the illness, preference for
and past experience with sources of care.
3. Cultural factors
related to psychosocial environment and levels of functioning: culturally relevant
interpretations of social stressors, available social supports, levels of functioning and
disability.
4. Cultural elements of
the relationship between the client and the clinician: differences in culture
and social status between the client and the clinician and the problems that these
differences may cause in diagnosis and treatment.
5. Overall cultural
assessment for diagnosis and care: discussion of how cultural considerations influence
diagnosis and care.
The guidelines are meant to “supplement the multi-axial
diagnostic assessment and to address difficulties that may be encountered in
applying DSM-IV criteria in a multicultural environment” (APA, 2000, p. 897). The
DSM-IV-TR also provides a glossary of 30 culture-bound syndromes, which are
“localized, folk, diagnostic categories” generally limited to specific societies or
cultures and may or may not be linked to a specific diagnostic category (APA, 2000,
p. 898). Becoming familiar with the categories listed in the glossary can assist
clinicians with recognizing culture-specific conditions that may be apparent in an
intake interview and integrated into a diagnostic formulation.
Appraisal of client’s cultural background should be a
standard part of any clinical or diagnostic interview. However, a word of
caution with regard to issues of diversity: “Although it is critical for clinicians to
have a basic understanding of the generic characteristics of counseling and
psychotherapy and the culture-specific life values of different groups, overgeneralizing and
stereotyping are ever-present dangers” (Sue & Sue, 2008, p. 154). While
generalizations are guidelines for behaviors, they should be tentatively applied in new
situations and open to change and challenge (Sue & Sue, 2008).
In addition, because each person has multiple identity dimensions,
clinicians should be cognizant of the many within-group differences that can
exist between members of a cultural group, which can sometimes outnumber the between-group
differences. For example, differences between individuals considered to be in
the same racial or ethnic group can be due to any number of factors, such as varying
national origin, socioeconomic class, level of acculturation, age, or gender, to name a few.
Moreover, clinicians should not automatically assume that the problems of
culturally diverse clients are necessarily related to cultural experiences or
background. For example, it would be erroneous to assume that an 85-year old-client is
depressed because of age alone.
Readers are encouraged to consult a number of sources that
cover issues of diversity more comprehensively: DHHS (2001); Paniagua (2005);
Pedersen, Draguns,
Lonner, and Trimble (2008); and Sue and Sue (2008).
References
Daniel L. Segal and Michel Hersen, Diagnostic Interviewing, Fourth
Edition, 2010, Springer
Read Also
The International Classification of Diseases (ICD)
Creating Cultural Competence in Practitioners
Culture, Ethnicity, and Race
