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