1. Cultural considerations
COUN 5480
Cultural considerations

2. Discussion What is abnormal? Who defines abnormal?
List implications of medicalizing and psychologizing behavioral and emotional distress.

3. Discussion Who decides what goes in DSM?
Can science ever be objective?
How do diagnoses perpetuate societal views?

4. Why attend to culture? Risk becoming “agents of social control”
“Practitioners … tend to label any deviations that they find upsetting or repellant as pathological solely because they trouble the practitioner” (Eriksen & Kress, 2005).
REACTIONS? EXAMPLES?

5. History and current experiences of abuses

6. Why attend to culture?
Tendency to overdiagnose, misdiagnose, underdiagnose
Experiences with status / isms
Not all “diverse” present with same
Language/communication style influences
Our stereotypes play role

7. Problems with the DSM Inaccurate with diverse populations
People of color excluded from dev
Locates problem in individual
Lack of culture-specific syndromes or culture-bound syndromes related to macrolevel issues
Culture affects perceptions of reality

8. Sources of diagnostic bias
Diagnostic sampling bias
Diagnostic assessment bias
Stereotyping
Data availability and vividness
Self-confirmatory bias
Self-fulfilling prophecy
Diagnostic criterion bias

9. Diagnostic sampling bias
“Significant differences between a particular diagnostic sample and the population it is taken to represent”
e.g., Assumptions about PTSD and Veterans when only look at VA
e.g., Assumptions about ADHD bx when only observe in MD office

10. Diagnostic assessment bias
“Flaws in gathering or processing clinical information lead to misdiagnosis”
Problems assigning criteria
Use subset
Assign even when criteria are not met
Human information processing errors

11. Diagnostic assessment bias: Stereotyping
Automatic decisions based on cognitive schemas. Decide based on clinical stereotypes.
e.g., believe women’s relationship patterns are unhealthy  see complaints as indicative of BPD or DPD

12. Diagnostic assessment bias: Data availability & vividness
“Categorizing based on familiarity, ease of recall, or salience”
Some criteria easier to remember  diagnostic overshadowing
Primacy effects
e.g., Remember and use 6 of 9 depression criteria

13. Diagnostic assessment bias: Self-confirmatory bias
“Focusing only on confirmatory information”
Have a “hunch” and check it out
Forget about rule-outs
e.g., check out schizophrenia criteria but don’t assess substance use

14. Diagnostic assessment bias: Self-fulfilling prophecy
Act on expectation in a way that confirms it.
e.g., Rosenhan’s (1973) experiment
e.g., Assume  respond differently  client responds

15. Diagnostic criterion bias
Criteria are “more valid for one group than for another”
“White male standard of adjustment”
Neglect social challenges

16. Reducing bias (McLaughlin, 2002)
Consider the source
Pay attention to work setting influence
Focus on the atypical
Use your criteria
Consider co-morbidity
Do differential diagnosis

17. Reducing bias Use sign/symptom checklist as standard ax
Make balance sheet of pros and cons
Use other assessment measures
Make expectations explicit
Keep social factors in mind
Be ethical
Get training related to diversity

18. Back to a
focus on
culture

19. 6 effects of culture: Pathogenic
Culture direct cause of psychopathology
Woman must give birth to son  Anxiety
Pressures regarding “success”

20. 6 effects of culture: Pathoselective
People in culture select particular ways of expressing emotional pain
Running amok
Bereavement
Physical symptoms
Suicide
Violence

21. 6 effects of culture: Pathoplastic
How sxs are manifested varies by culture
Content of phobias, obsessions, delusions
Exaggerated in some
Absent in others

22. 6 effects of culture: Pathoelaborating
Cultural factors contribute to the frequent occurrence of certain mental disorders
Influences on general life patterns
Prevalence of suicide
Prevalence of substance use

23. 6 effects of culture: Pathoreactive
Cultural factors affect understandings and beliefs about the disorder, how react, and how express suffering
Experience of PTSD depends on reaction:
Empathy
Benefits
Ignored

24. Into practice… DSM Cultural formulation
Cultural identity of individual
Reference groups
Degree of involvement
Language
Religious beliefs
Education, employment
Social status, social relations, gender roles
Media usage, identity models

25. Into practice… DSM Cultural formulation
Cultural explanations of illness
How communicate distress
Meaning of sxs
Perceived severity of sxs
Perceived causes
Previous experiences

26. Into practice… DSM Cultural formulation
Psychosocial environment & functioning
Interpretations of social stressors
Available supports
Spiritual
Family / kin
Community
Work
Stigmas

27. Into practice… DSM Cultural formulation
Counselor-client relationship
Differences in status
Differences in culture
Differences in language, understanding

28. Practice considerations
Increase emphasis on Axis IV
Increase personal awareness
Collaborative dx and tx
Use culturally sensitive skills