CLASS 4
Cultural Considerations
Introduction to Dx and Tx
Culture and Abnormality
“The critical component of effective cross-cultural work is developing a working knowledge of our own worldview, including the biases we bring to our work with others.” (Rodriguez, 2004)
How does the case of Juan Gonzalez show that awareness of alternative worldviews is vital to providing competent and effective mental health treatment?
Cultural Considerations
Cultures that can be found in the U.S. may differ in the following areas (Arthur, 2004) : Family structure Sex and gender roles Roles of individual family members Religious beliefs and practices History and traditions Rules for interpersonal interaction Dress and appearance Life aspirations Linguistic and communication rules Individual vs. collective perspective
Cultural Considerations
Be mindful of factors that could create a barrier to effective treatment for some minorities or people of non-Western cultural orientation: Language Mistrust of established authority Immigration status Attitudes about privacy Attitudes about mental illness
Culture and DSM-5
DSM-5 acknowledges that: “Understanding the cultural context of
illness experienced is essential for effective diagnostic assessment and clinical
management” (p.749).
DSM-5 seems to take a much more integrated view of culture’s involvement with mental health than did DSM-IV.
Culture and DSM-5
Cultural concepts and understanding are important to Dx: To avoid misdiagnosis To get useful clinical information To improve clinical rapport and engagement To improve Tx efficacy
DSM-5 includes multiple options for considering cultural impact on psychiatric Dx.
Culture and DSM-5
Outline for Cultural Formulation - 5 categories: Cultural identity of the individual Cultural conceptualization of distress (See DSM, p. 758)
Psychosocial stressors and cultural features of vulnerability and resilience
Cultural features of the relationship between the individual and the clinician
Overall cultural assessment
Culture and DSM-5
DSM may not adequately recognize that Sx of some “disorders” may: vary by culture… Depression is expressed as physical Sx in many non-
Western cultures …or be normal variations of Bx or
experience for some cultures. E.g., hearing voices or dissociation is not
universally indicative of psychopathology Some DSM disorders are culturally bound
syndromesClinical judgment is vital to ensuring
clients are not over- or under- diagnosed.
DSM-5
Purpose of DSM is to: Be a “practical, functional, and flexible guide” to
“aid in the accurate diagnosis and treatment of mental disorders” (DSM-5, p. xli).
Create a common nomenclature and characterization of disorders
Be a reference tool for research Serve as an educational resource
DSM-5
DSM diagnostic system is based on: Descriptive (non-etiological) approach
Signs (objective) Symptoms (subjective) Natural and social history
Categorical approach DSM taskforce recognized problems with this
approach, but felt it scientifically premature to alter it. Medical model
Illness is inside a person Emphasis on illness, not health
Diagnosis
2 main purposes of Diagnosis: Define clinical entities and create common
understanding of what a certain Dx means DETERMINE TREATMENT
Inaccurate Dx can lead to ineffective and/or harmful Tx
Differential Diagnosis: the process of choosing the correct Dx from
conditions with similar features A list of diagnoses that are possible and should be
considered for a given patient
Diagnosis
Things to consider when making a Dx Always rule out other medical conditions and substance
involvement in presenting Sx picture Consider how cultural and/or developmental factors may
affect Sx presentation and your interpretation of Sx Consider options for indicating diagnostic uncertainty Follow the principle of “parsimony”
Use as few Dx as possible to account for all clinical information and Sx
Consider reliability of sources
DSM Diagnosis
Principal Diagnosis – the condition that is chiefly responsible for services provided This Dx is usually listed first with other Dx listed in
order of focus of attention and TxProvisional Diagnosis – This is used when
you strongly presume full criteria will be met for a Dx, but current information is not sufficient to make a firm Dx This is indicated by “(Provisional)” after the Dx
name
Sample DSM Diagnosis
300.02 Generalized Anxiety Disorder300.4 Persistent Depressive Disorder, With
Anxious Distress, Mild (Provisional)V62.29 Other Problem Related to
EmploymentDiabetes, type II (per patient report)
Sample DSM Diagnosis
301.83 Borderline Personality Disorder305.00 Alcohol Use Disorder, MildV61.10 Relationship Distress With Spouse or
Intimate PartnerV62.29 Other Problem Related to
Employment
Limitations of the DSM
Categorizing reinforces seeing disorders as discrete entities/reifying disorders
When people being categorized aren’t homogenous, there can be bias problems
Encourages assumptions regarding similarity of people with same Dx
Can encourage clinicians to replace their own judgment with that of DSM
Can be overly rigidly interpreted
Criticism of DSM-5
Encourages overdiagnosis and overtreatment. Thresholds for some Dx reduced Particular concerns regarding potential for overmedication
Concerns that this will lead public and political forces to devalue mental health evaluation and Tx
Questions about objectivity, validity, and reliability of scientific information used to create DSM-5
NIMH divorced itself from DSM-5 and will develop its own diagnostic system on which to base research projects.
Treatment Planning
Purpose of Tx planning: To “facilitate effective delivery of mental health
services.” Helps clinicians make sound therapeutic decisions
to help improve clients’ lives. To create accountability. A plan helps clinicians
demonstrate that Tx is based on interventions that have a likelihood of effectiveness with client’s Sx/Dx.
Helps clinicians be clear on what has been effective, and might be so with other clients.
Considerations for Creating Tx Plan
Diagnostic certaintyUrgency of TxPrioritize problems
Prioritize problems that could lead to physical harm to client or someone else or to a decline in client’s medical status
Client resourcesContraindications Consideration of all feasible Tx modalitiesEnsure integration of Dx and Tx choices
Biological Treatments
Psychotropic medication Antidepressants Antipsychotics (neuroleptics) Anxiolytics Lithium/Mood Stabilizers/Anticonvulsants Stimulants Drugs to impact Alzheimer’s Disease Herbals/Non-pharmaceuticals
Electroconvulsive Therapy Psychosurgery
Psychological Treatments
Individual Insight-oriented psychotherapy/Analysis
Defense mechanisms Interpretation/transference
Cognitive/cognitive-behavioral therapy Negative automatic thoughts/irrational beliefs Disputing and replacing beliefs
Behavioral Therapy Systematic desensitization Reinforcement/shaping
Group Disease-oriented (AA) Group therapy (interpersonal) Education of Client Support Family/couples
Social Interventions
Vocational rehabilitationSocial Skills trainingEducation of familyPlacement in a facility (acute, intermediate,
chronic)Involuntary commitmentConservatorshipInteraction with community
agencies/resources
DO A CLIENT MAP
DiagnosisObjectives of TxAssessmentsClinician CharacteristicsLocation of TxInterventionsEmphasis of TxNumbersTimingMedicationsAdjunct ServicesPrognosis
Treatment
Determinants of Tx outcome, once plan is in place Therapist-related variables
Ability to form and maintain alliance is highly correlated with better outcome
Client-related variables Diagnosis Expectations of and motivation for Tx
The therapeutic alliance Match between client and therapist variables Agreement on goals and how to reach them
Treatment variables