CHAPTER 18 Multicultural Diagnosis and Conceptualization Developing Multicultural

CHAPTER 18: Multicultural Diagnosis and Conceptualization Developing Multicultural Counseling Competence: A Systems Approach Second Edition Danica G. Hays and Bradley T. Erford

The Challenge of Ethical Practice • Competence in conducting an overall cultural assessment • Cultural framework of the client’s identity • Cultural explanations of illness experiences & help seeking behavior • Cultural meanings of adaptive functioning & social context • Cultural elements in the counselor-client relationship • Culturally sensitive diagnosis & conceptualization is easier to talk about than to actually do because wide variations exist about “normal” behavior • Utility of the Diagnostic and Statistical Manual of Mental Disorders (DSM) system has been challenged for people who differ from the majority culture Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -2

Normal vs. Abnormal Who gets to decide what is abnormal? What is mental illness? Where is the line between normal & abnormal? • The expansion of boundaries of abnormality make it harder for people to be assessed as “normal” • Professional constructs of personality & psychopathology are mostly culturally bound, reflecting the experiences of specific cohorts, producing “category fallacy” • Historically, people who have not conformed to societal norms have been hospitalized, ostracized from their communities, and prevented from marrying and working • Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -3

Overdiagnosis, Underdiagnosis, & Misdiagnosis • Behavior that does not match Western norms is sometimes labeled as pathological (e. g. , gay men, lesbians, racial/ethnic minorities, women, nontraditional men) and may be overdiagnosed or misdiagnosed with certain disorders • Misdiagnosis occurs as a result of stereotyping and overlooking perspectives of women and the poor • Bias seems to occur when one cultural group tolerates a higher level of misbehavior than another Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -4

Sampling Bias • Sampling has included a disproportionate representation of the sexes • These research omissions raise questions about: • success in developing unbiased diagnostic criteria • the relevance of applying current diagnoses to women and people of color • the appropriateness and availability of treatments that are based on such diagnoses • power and social control Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -5

Culture & Psychopathology • Culture allows individuals to define, express, and interpret the dynamic beliefs, values, and customs of a social group • Consider the interaction of race and ethnicity and diagnosis • Cross-cultural research examples • Limitations seem to indicate that the DSM represents Western thought & assumptions, representing a minority bias. • The DSM does include culture-specific psychological problems in the appendices Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -6

Feminist Challenges • Feminist theorists believe that women’s anger, depression, and discontent have been reframed as medical or psychiatric symptoms • Roots of women’s so-called psychological problems have many times been social and political, rather than individual and intrapsychic in origin • Stigmatizing effects of diagnostic labels that are embedded in both the International Classification of Diseases (ICD) and the DSM. • Affects the ability to use classification systems for treatment or conceptualizing the counseling process Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -7

Gender and Diagnoses • Mixed research on the prevalence of mental illness by gender for overall rates, but not specific disorders • Males: higher for substance abuse and sexually related disorders, along with antisocial, compulsive, paranoid, schizoid, and passive aggressive personality disorders (in all age groups except 31 -40 years) • Females: higher for all forms of mood disorders and anxiety disorders, and borderline, dependent, and histrionic personality disorders • Few gender differences in diagnosis prevalent before school age Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -8

Developmental Shifts in Prevalence • Children, in general, are often overdiagnosed and misdiagnosed (ADHD, depression, conduct disorders, substance abuse disorders) • Inappropriate diagnoses may result in labels that follow children into adulthood, which leads to great ethical concern • Counselors may struggle with differentiating normal aging concerns from symptoms of depression or dementia • Psychological symptoms may also be caused by a physical disorder or medications to treat a medical problem Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -9

Sex Bias in Diagnosis • Underconforming and overconforming to sex roles can harm both men & women • Female & male clients may receive different diagnoses even when presenting with identical symptoms • Greater risk of sex bias for those of multiple oppressed statuses • Premenstrual Dysphoric Disorder • Personality disorders and socialization • Overlap of criteria and gender roles Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -10

Socialization & Mental Health • Gilligan and colleagues’ research on “voice” • During adolescence, boys are taught that men are independent and active, whereas girls are taught that women are passive, compliant, and committed to interpersonal relationships • Bern (1974) indicated that suppression of the non-sex-typed part of oneself was unhealthy, & that androgyny resulted in better mental health and adjustment Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -11

Social Conditions • Causes of depression and other disorders among women • May be more accurate to say that a disorder exists in the relationships between certain people and those with whom they relate, or between those people and societal norms/demands • Women’s trauma experiences: • Gender differentiation in our society results in violence against women • Effects of sexual abuse and sexual assault welldocumented • Despair, anger, re-traumatization, PTSD, depression, anxiety, eating disorders, and borderline personality disorder • Abusive/Oppression Artifact Disorder has been proposed to clarify etiology for counselors Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -12

Toward Solutions • Conducting a comprehensive assessment • Considering diagnoses as case-and-situation specific, as evolving information • Universal versus culturally specific diagnoses • Adding cultural data to the DSM has generated criticism • Proposed contents of a culturally-sensitive DSM Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -13

Toward Solutions Continued • Counselors should explore: • Cultural systems and structures (e. g. , community structure, family, schools, interaction styles, concepts of illness, lifestage development, coping patterns, immigration history) • Cultural values (e. g. , time, activity, relational orientation, person-nature orientation, basic nature of people • Gender socialization • Effects of trauma Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -14

Culturally Astute Strategies • An accurate assessment of emotion and behavior is not possible without the assessment of cultural schemas • Counselors must be aware of: • The types of emotions a particular cultural group experiences • Emotions elicited by what situations • The means of expression • Proper and improper emotions at certain social statuses • How unexpressed emotions are handled Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -15

Culturally Astute Strategies Cont. • Assess the client’s cultural identity • Identify sources of cultural information relevant to the client • Assess the cultural meaning of a client’s problem and symptoms • Consider the impact and effect of family, work, and community on the complaint, including stigma and discrimination that may be associated with mental illness in the client’s culture • Assess personal biases • Plan treatment collaboratively Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -16

Culturally Astute Strategies Cont. • Questions for culturally sensitive counselors: • Have I been able to separate what is important to me and what is important to this particular client? • What do I know about this client’s cultural heritage? • What is this client’s relationship with his or her culture from his or her perspective? • How acculturated is the client? Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -17

Culturally Astute Strategies Cont. • What are my stereotypes, beliefs, and biases about this culture, and how might these influence my understandings? • What culturally appropriate strategies or techniques should be incorporated in the assessment process? • What is my philosophy of how pathology is operationalized in individuals from this cultural group? • Have I appropriately consulted with other mental health professionals, members from this particular culture, and/or members of this client’s family or extended family? Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -18

Feminist Analysis • Proposes that traditional approaches to diagnosis and treatment focus too much on idiosyncratic life experiences, biology, or personality traits as causes of problems • Counselors are to conduct feminist clinical assessments and continually question their own assumptions about what is normal with respect to gender • Counselors must also be aware of: • Issues, patterns or behavior that occur with high frequency in one gender or the other • Cultural reasons for men and women’s positions in society • Impact on men and women’s expressions of distress or types of problems Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -19

Function of Symptoms in Context • Counselors may experience difficulties including social and environmental influences in the DSM’s multiaxial system • Counselors may realize that what the DSM considers to be psychopathology may actually be a very functional attempt on a person’s part to adapt to or cope with a dysfunctional context • Conceptualizing symptoms as adaptations or coping strategies may also result in a different counselor-client relationship Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -20

Relational (and Other Theoretical) Systems of Diagnosis • The DSM has become more relationally oriented as a result of efforts by the Coalition on Family Diagnosis (CFD) • Expansion of the V Codes to include “Relational Problems” and “Other Conditions that May be a Focus of Clinical Attention”, as well as promoting the Global Assessment of Relational Functioning (GARF) • Some theorists have developed assessment models that more predominantly include relational factors that are pertinent to DSM diagnoses • Axis VI for family evaluation Hays & Erford, Developing Multicultural Counseling Competence: A Systems Approach (2 nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved 18 -21