How Do We Consider Culture in Diagnosis and Treatment?

Cultural variation (or the lack of cultural variation) in the occurrence and course of mental illness and in the presentation of psychiatric symptoms all have implications for treatment. Most importantly, they highlight aspects of psychotherapy and other psychiatric treatments that may require modification to be effective with different cultural groups. Given that individuals vary in the extent to which they demonstrate culturally normative behavior and that there is considerable variability in empirically based knowledge about cultural influences on psychopathology, clinicians should use clinical recommendations judiciously. These recommendations should lead to culture-related hypotheses about client dysfunction that require additional data specific to the client (and to the specific form of distress) for support. Because cultural considerations become more salient when working with individuals of cultural backgrounds different from one’s own, the next section will discuss diagnosis and treatment in multicultural settings such as the United States. Cultural Patterns of Service Utilization.

Ethnic groups in the United States vary in their rates of mental health service utilization. These rates may reflect cultural attitudes toward mental health treatment. For example, compared to White Americans, Asian-Americans tend to ‘‘underutilize’’ services. Asian-Americans tend to seek help from family members, medical services (Western and Asian), and community services before using mental health services. As a result, Asian-Americans may enter mental health treatment with little optimism about their recovery which may interfere with treatment outcome. Clinicians may have to consider these attitudes toward treatment when formulating a treatment plan. In addition, because Asian-Americans use mental health services as a last resort, those who enter mental health settings tend to be the most severely distressed. Thus, clinicians may have to provide more acute care to these individuals. Similar issues may arise for members of other cultural and ethnic groups. Cultural Diagnosis.Although culture may shape the experience and expression of distress, this may vary across individuals. Individuals within cultural groups vary in the extent to which they endorse the values, norms, and beliefs of their cultural group and the meanings of their cultural identity. In diagnosis, understanding an individual’s cultural orientation will help clinicians assess how an individual’s expressions of distress are culturally shaped, as well as prevent errors of misdiagnosis. For example, although African-American and Hispanic clients with affective disorders often report more delusions and hallucinations than their White American counterparts, this may not hold for a specific African-American or Hispanic individual. It is possible that under specific circumstances, one’s cultural heritage is less relevant to one’s symptoms than other influences, such as one’s socioeconomic status. Therefore, a critical aspect of diagnosis, especially with patients of different cultural backgrounds, is assessing the patients’ cultural history, cultural identity and orientation, and subjective experience of culture. Therapist and Client Interactions.The current DSM-IV contains guidelines for conducting a ‘‘cultural formulation,’’ or assessing how cultural factors influence a client’s psychology. These guidelines also emphasize the importance of assessing the cultural aspects of the therapist–client relationship. Cultures vary in their emphasis on and expectations of interpersonal relationships.

Clinicians’ ability to establish rapport with clients of different cultural backgrounds may hinge on their knowledge of the clients’ cultural expectations for the therapist–client relationship. In some cases, this rapport is critical. For example, an overwhelming majority of Asian-American patients discontinue mental health treatment after the first session. These drop-out rates, however, are significantly reduced when the therapist has the same ethnocultural background as the client. Similarly, Takeuchi, Sue, and Yeh found that in Los Angeles, Asian-American, African-American, and Mexican-American patients were more likely to continue in mental health programs if the programs were oriented toward their specific ethnic heritage. Culture may influence different aspects of the clinician–patient interaction. First, culture may influence nonverbal communication (e.g., interpersonal space, body movement, paralanguage, eye contact). For example, in Asian cultural groups, clinicians are considered authority figures, and therefore, clients may avert their gaze as an expression of deference and respect. This behavior is a culturally appropriate response, rather than an indication of abnormal interpersonal behavior. Second, culture may influence expectations of therapist credibility (e.g., expertise and trustworthiness). Certain groups may explicitly inquire about clinicians’ credentials or may require demonstration of clinical expertise before engaging in treatment. Again, this may be considered a culturally appropriate response rather than an anomalous response to treatment. Third, culture may influence expectations of the therapist–client relationship. For example, whereas some cultural groups may expect a formal interaction style between clinician and client, other cultural groups may expect an informal interactional style. In these cases, patients may expect clinicians to share personal information as a way of demonstrating their trustworthiness. Finally, cultural groups may vary in their exposure to and experience with mental health services; therefore, patients may require explicit education about the process of and regulations related to treatment. Cultural Adaptations of Treatment.The most popular treatments for mental disorders in psychiatric settings were developed for use with mainstream European-American populations. Many clinicians have recommended ways of adapting Western treatments for culturally diverse populations. We discuss a few of these adaptations here. Many Western treatments must be adapted for culturally diverse populations because their basic cultural assumptions may not apply to nonWestern cultural groups. For example, Randall argues that the concepts of time and self that underlie cognitive therapy stem from a Western European cultural tradition that may differ for ethnic clients. Minority clients from cultures in which time is less salient and concepts of the self are more sociocentric than in Western cultures may not do as well in cognitive therapy. Randall proposes changes to traditional forms of cognitive therapy that may make it more relevant for one such cultural group, African-American women. Even in medication treatments, research has demonstrated that ‘‘standard’’ dosages of psychotropic medications must be modified when administered to specific ethnic groups. For example, Lin, Poland, and Lesser found that AsianAmerican patients often require only half of the standard ‘‘European-American’’ dosage of psychotropic medications. Other adaptations include greater involvement of the family in treatment. In cultures that emphasize familialism, treating the individual without the family may be counterproductive and culturally inappropriate. In addition, when working with members of different cultural groups, clinicians often must employ interpreters. In these cases, culturally sensitive nonverbal communication is even more critical in developing rapport with the client.

Moreover, clinicians must develop a positive working relationship with the interpreter before obtaining rapport with the client. Finally, Western forms of treatment may have to work in collaboration with non-Western forms of treatment. Patients may be using traditional medicines or seeking the help of traditional healers while they are seeking treatment in Western psychiatric settings. In summary, when working with individuals of cultural backgrounds different from one’s own, it becomes imperative that clinicians entertain hypotheses that account for cultural differences at all stages of diagnosis and treatment. The extent to which cultural considerations should be included in diagnosis and treatment, however, depends on the specific individual.