Download Multicultural Diagnosis and Conceptualization

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
(2nd 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
(2nd 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
(2nd 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
(2nd 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
(2nd 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
(2nd 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
(2nd 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
(2nd 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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-10
Socialization & Mental Health
•
Gilligan and colleagues’ research on
“voice”
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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
(2nd 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:
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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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-12
Toward Solutions
•
Conducting a comprehensive assessment
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Considering diagnoses as case-andsituation 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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-13
Toward Solutions Continued
•
Counselors should explore:
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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
(2nd 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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-15
Culturally Astute Strategies
Cont.
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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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-16
Culturally Astute Strategies
Cont.
•
Questions for culturally sensitive
counselors:
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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
(2nd 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
(2nd 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:
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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
(2nd 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
(2nd 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
(2nd Edition) © 2013, 2009 by Pearson Education, Inc. All Rights Reserved
18-21