The Impact Of Group Membership homework help
CULTURALLY COMPETENT ASSESSMENT
David Sue and Diane M. Sue
Chapter Objectives
1. Understand the many variables that influence assessment, diagnosis, and case conceptualization.
2. Develop awareness of the dangers of stereotyping and the importance of appreciating the individuality of each client.
3. Learn how cultural competence prevents diagnostic errors.
4. Understand contextual and collaborative assessment.
5. Understand DSM-5 cultural formulations.
6. Learn how to infuse cultural competence into standard clinical assessments.
“Bias is a very real issue,” said Francis Lu, a psychiatrist at the University of California at San Francisco. “We don’t talk about it—it’s upsetting. We see ourselves as unbiased and rational and scientific.”. . .Psychiatrist Heather Hall, a colleague of Lu’s, said she had to correct the diagnoses of about 40 minorities over a two-year period. . . Advocates for cultural competence say both clinicians and patients are unwilling to acknowledge that race might matter: “In a cross-cultural situation, race or ethnicity is the white elephant in the room,” said Lillian Comas-Diaz. (Vedantam, 2005, p. 1)
Accurate assessment, diagnosis, and case conceptualization, key prerequisites to the provision of appropriate treatment, are dependent upon the characteristics, values, and worldviews of both the therapist and the client (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006). Most clinicians recognize that client variables, such as socioeconomic status, gender, and racial or cultural background, can significantly affect assessment, diagnosis, and conceptualization. However, we often forget that as clinicians we are not “objective” observers of our clients. Instead, we each have our own set of beliefs, values, and theoretical assumptions. To reduce error, a mental health professional must be aware of potential biases that can affect clinical judgment, including the influence of stereotypes (i.e., generalizations based on limited or inaccurate information). Unfortunately, our current methods of assessment and diagnosis often do not adequately consider these factors, especially with respect to therapist variables. Additionally, many of our instruments and processes for assessment and diagnosis do not address client variables in a meaningful manner.
If we are to follow best-practice guidelines and the ethical standards of our profession, we must consider broad background factors, including the worldview of each client. How can this be accomplished? First and foremost, it is critical that we operate from the awareness that a thorough understanding of our clients’ beliefs, expectations, and experiences is an essential aspect of the assessment and case conceptualization process. We believe that culturally competent assessment occurs through a combination of evidence-based guidelines for assessment and a cultural competency framework.
In this chapter we will cover (a) the impact of therapist variables on assessment and diagnosis, emphasizing the dangers of stereotyping; (b) ways in which culturally competent practices can reduce diagnostic errors; (c) contextual and collaborative assessment; and (d) ideas for infusing cultural competence into standard intake and assessment procedures. Careful consideration of these factors when using evidence-based guidelines to conduct assessment will ensure that clinicians form an accurate and complete picture of the problems and issues facing each client. We will demonstrate how culturally competent assessment should be conducted—in a manner that considers the unique background, values, and beliefs of each client. We hope that as you proceed through the final chapters of this book—chapters describing general characteristics and special challenges faced by various oppressed populations—you will remember that we are providing this information so you will have some knowledge of the specific research and the sociopolitical and cultural factors that might be pertinent to a client or family from the population being discussed. However, it is critical that when counseling diverse clientele you actively work to avoid succumbing to stereotypes (i.e., basing your opinions of the client on limited information or prior assumptions). Instead, your task is to develop an in-depth understanding of each client, taking into consideration the individual’s unique personal background and worldview. By doing this, you will be in a position to develop an individually tailored treatment plan that effectively addresses presenting problems in a culturally sensitive manner.
Therapist Variables Affecting Diagnosis
Assessment is best conceptualized as a two-way street, influenced by both client and therapist variables. Because humans filter observations through their own set of values and beliefs, we begin our discussion by focusing on therapist self-assessment.
A treatment team observing a clinical interview erupted in laughter when the foreign-born psychiatric resident attempted to find out what caused or precipitated the client’s problem. In poor and halting English, the resident asked, “How brought you to the hospital?” The patient responded, “I came by car.” (Chambliss, 2000, pp. 186)
Later, during the case conference, the psychiatric resident attributed the patient’s response to concrete thinking, a characteristic sometimes displayed by people with schizophrenia. The rest of the treatment team, however, believed the response was due to a poorly worded question. This example illustrates what can occur when therapists focus solely on the client without considering the impact of therapist variables. Personal characteristics, attitudes, and beliefs can (and do) influence how assessment is conducted and what is assessed, as well as interpretations of clinical data. Counselors and other mental health professionals are often unaware of how strongly personal beliefs can affect clinical judgment.
In one study, 108 psychotherapists read an intake report involving a male client whose sexuality was revealed through references to his previous and present partners; all clinical data were identical with the exception of references to sexual orientation. Details suggesting heterosexual or same-sex orientation had little impact on clinical ratings; however, therapists given data suggesting the client was bisexual were more likely to “detect” emotional disturbance. The researchers concluded that these differing diagnostic perceptions were the result of stereotypes of bisexual men being “confused and conflicted” (Mohr, Weiner, Chopp, & Wong, 2009).
In conducting culturally competent assessment, we must not only be aware of the influence of stereotypes but also be alert for common diagnostic errors such as the following:
· Confirmatory strategy: Searching for evidence or information that supports one’s hypothesis and ignoring data that are inconsistent with this perspective. When working with clients, mental health professionals might search for information that confirms beliefs based on their worldviews or theoretical orientation (Osmo & Rosen, 2002). In a similar manner, our views or stereotypes of the characteristics and values of ethnic and other diverse groups can act as blinders when working with clients from these groups. Counselors can combat this type of error by working cooperatively with clients to understand and interpret the presenting problem. Diagnostic accuracy is increased when clinicians test any hypotheses they formulate with the client. When determining whether these possible interpretations resonate with the client, it is critical that the therapist be open to both confirmatory and disconfirmatory information.
· Attribution error : The therapist places an undue emphasis on internal causes regarding a client’s problem. For example, a therapist might interpret a problem as stemming from a personal characteristic of the client rather than considering environmental or sociocultural explanations such as poverty, discrimination, or oppression. Attribution error can be reduced by performing a thorough assessment that includes consideration of sociocultural and environmental factors and testing hypotheses regarding extrapsychic (i.e., residing outside the person) as well as intrapsychic (residing within the person) influences.
· Judgmental heuristics : Commonly used quick-decision rules. These can be problematic because they short-circuit our ability to engage in self-correction. For example, if we quickly identify our client as “defensive” or “overreactive,” these characterizations will reduce our attempt to gather additional or contradictory information. In one study (Stewart, 2004), 300 clinicians received identical vignettes regarding hypothetical clients, with the only difference being the clients’ stated birth order. Birth order influenced the judgment of the clinicians, including the expected prognosis for the client, even though there is little research support for personality differences associated with birth order. These kinds of beliefs or spontaneous associations occur automatically and need to be identified and addressed. Therapists can reduce this tendency by acknowledging the existence of judgmental heuristics, questioning the basis for quick decisions, assessing additional factors, and evaluating the accuracy of opinions about clients.
· Diagnostic overshadowing : The client’s problem receives inadequate treatment because attention is diverted to a more salient characteristic. For example, individuals who are gay or lesbian can have a number of psychological issues that have nothing to do with their sexual orientation. In diagnostic overshadowing, a therapist might perceive the presenting problem as related to conflicts over sexual orientation and fail to address other critical issues. Other salient characteristics are race, religious affiliation, and visible disabilities.
We must be aware of our beliefs and values as we work with clients and their specific presenting problems. We are all susceptible to making errors in clinical judgment during assessment; therefore it is important to adopt a tentative stance and test out our observations. Those who remember that errors in judgment are possible can reduce their effect by using a self-corrective model. In the next section, for example, we discuss why it is important to consider whether the current focus on cultural competence may, in fact, be creating new sources of errors—errors resulting from applying cultural information in a stereotypic, “one-size-fits-all” manner.
Cultural Competence and Preventing Diagnostic Errors
Regina, a mixed-race (Asian/White) student felt that her therapist had “this kind of book-learned. . .image of some kind of immigrant family, instead of. . .an emotional understanding of what it’s like to be Asian in [specific small city, in the intermountain West].” (Chang & Berk, 2009, p. 527)
“You shouldn’t expect a lot of African American clients to be in touch with their feelings and do some real intrapsychic work. Sometimes you have to be more directive and problem-focused in dealing with Black people.” (Constantine & Sue, 2007, p. 146)
Given the growing multicultural nature of the United States population, all mental health organizations now promote cultural competence and the ability to work effectively with multicultural clients. However, is it possible that this focus on cultural differences is creating unintended consequences? Is the emphasis on understanding cultural factors leading to problems such as stereotyping or the blind application of cultural information? The two previous examples illustrate the problems that can occur when general cultural information is applied to clients without assessing for individual differences. Surprisingly, in the second case, the speaker was a supervisor giving stereotype-based advice to her supervisee.
Multicultural awareness can, in fact, lead to diagnostic overshadowing if a clinician’s attention to race or other diversity characteristics results in neglect of important aspects of the client (Vontress & Jackson, 2004). This tendency is increased in workshops and classes that focus primarily on the memorization of cultural information (Kissinger, 2014). As clinicians working with diverse populations, we need to consider all aspects of each client’s life and not automatically assume that presenting problems are based on racial or diversity issues. In fact, it would be irresponsible for a clinician to focus on a client’s diversity or environmental stressors when there are other significant concerns (Weinrach & Thomas, 2004).
Some mental health professionals have argued that the emphasis on culture and the development of culture-specific approaches have led to fragmentation, confusion, and controversy in the field of counseling and psychotherapy. Diversity training has been accused of producing “professionally sanctioned stereotyping,” in which the therapist gives primary consideration to cultural attributes rather than focusing on understanding the uniqueness and life circumstances of the individual client (Freitag, Ottens, & Gross, 1999; D. W. Sue & D. Sue, 2013). Although it is important to understand group-specific differences, it is equally critical that we avoid a “cookbook” approach, in which the characteristics of different groups are memorized and applied to all clients who belong to a specific group (Lee, 2006).
Do guidelines for increasing cultural competence (e.g., increasing knowledge about different cultural groups and developing multicultural clinical skills) contribute to assessment errors, such as confirmatory bias, diagnostic overshadowing, or stereotyping? These errors certainly can happen and are most likely to occur when clinicians fail to use self-correcting strategies or fail to consider the individuality of each client. It is our belief that effective culturally competent assessment can, in fact, minimize the dangers of stereotyping or placing inordinate weight on race or other diversity issues.
Cultural competence is defined in different ways. We will use the definition focusing on the following three components: (a) self-awareness (i.e., self-reflection and awareness of one’s values and biases); (b) knowledge of culturally diverse groups (e.g., marginalized status, characteristics, strengths, norms, and values); and (c) specific clinical skills, including the ability to generate a wide variety of verbal and nonverbal helping responses, form a therapeutic alliance, and intervene at the individual, group, institutional, and societal levels. We believe that appropriate use of these aspects of cultural competence can prevent diagnostic and treatment errors due to inaccurate assumptions and stereotypes.
Cultural Competence: Self-Awareness
Self-awareness is important with respect to both cultural competency and evidence-based practice. Therapists may be unaware that stereotypes are affecting their views and/or responses to clients or that differences between themselves and their clients are affecting the therapeutic process. For example, studies have found that mental health professionals may pathologize clients who display nontraditional gender role behavior (Seem & Johnson, 1998) and may rate female clients as less competent than males (Danzinger & Welfel, 2000).
Such judgments (or inferential errors) constitute deviations from cultural competence and the evidence-based practice model of self-reflection and awareness regarding the impact of one’s values and beliefs. Identifying one’s biases or taking the time to self-reflect can help reduce such errors. Questions such as “Which of my identities allow me to experience privilege?” “Which identities expose me to oppression?” and “How do I feel about these experiences?” can help clinicians reflect on how their own backgrounds and experiences have shaped their worldviews (Singh & Chun, 2010, p. 36).
Further, we need to develop an awareness of our assessment processes and identify our values, theoretical orientation, and beliefs about different groups whose social, cultural, or ethnic backgrounds differ from our own. We might ask such questions as “Do I hold assumptions about gender roles, sexual orientation, older individuals, political philosophy, or ‘healthy’ family structure that may influence my clinical judgment?” “Do I hold certain stereotypes or impressions of the client or the cultural groups to which the client belongs?” Such self-assessment is a necessary step in working with clients who differ from us and is an important component of counselor competence (Ridley, Mollen, & Kelly, 2011).
Cultural Competence: Knowledge
The knowledge component of cultural competence involves the awareness of different worldviews (e.g., that the majority of cultures in the world have a collectivistic and interdependent orientation; that the structure of some families is hierarchical in nature). Such knowledge is crucial in working with ethnic minority populations. In our special-population chapters, you will encounter descriptions such as the following:
· African American families often show adaptability in family roles, strong kinship bonds, and a strong religious orientation.
· American Indian/Native American and Alaska Native families are often structured with the extended family as the basic family unit; children are frequently raised by aunts, uncles, and grandparents who live in separate households.
· Asian American families are often hierarchical and patriarchal in structure, with males typically having higher status than females.
· Latina/o American families tend to strongly value family unity (familismo). The extended family can include not only relatives but also godparents and close friends.
This type of cultural knowledge is useful in helping counselors understand family patterns commonly seen among different ethnic minority populations; such information can be particularly helpful when patterns differ from the family and relationship structure typical of White American families. However, these descriptions are “modal” cultural characteristics and may or may not be applicable to a particular client. Knowledge also involves the awareness that significant within-group differences can exist—individuals can vary, for example, in degree of acculturation, level of identification with cultural values, and unique personal experiences.
Cultural information should not be applied rigidly; it is necessary to determine the degree of fit between general cultural information and the individual client in front of us. Gone (2009), for example, points out that it is not enough to know that a client is American Indian; you need to ask, “What kind of Indian are you?” In other words, you need to learn what tribe the client is affiliated with (if any), the nature of connection with the tribe, and, if the client is closely connected, the particular values and practices of the tribal culture. Among ethnic minorities, within- and between-group differences are quite large—some individuals and families are quite acculturated, while others retain a more traditional cultural orientation. Cultural differences, such as the degree of assimilation, socioeconomic background, family experiences, and educational level, affect each individual in a unique manner.
Knowledge of cultural values associated with specific groups can help us generate hypotheses about the manner in which a client (or family members) might view a disorder. However, the accuracy of such cultural hypotheses must be assessed for each client. Thus it is critical that we communicate with the client in order to confirm or disconfirm any hypotheses generated from our cultural “knowledge.” In our opinion, the cultural competence component of “knowledge” requires not only that we be open to the worldview of others, but that we take care to remember that every client has a unique life story.
Cultural Competence: Multicultural Skills
The multicultural skills component of cultural competence requires that counselors effectively apply a variety of helping skills when forming a therapeutic alliance. As discussed in our chapter on evidence-based practice, it is important to individualize the choice of helping skills and avoid a blind application of techniques to all situations and all populations. Our manner of developing an effective therapeutic bond will differ from individual to individual and may differ from ethnic group to ethnic group. It is important to individualize relationship skills and to consistently evaluate the effectiveness of our verbal and nonverbal interactions with the client.
Research-based information regarding ethnic minorities (e.g., African Americans prefer an egalitarian therapeutic relationship; Asian Americans prefer a more formal relationship and concrete suggestions from the counselor; Latina/o Americans do better with a more personal relationship with the counselor; American Indians/Native American and Alaska Natives prefer a relaxed, client-centered listening style) can alert counselors to possible variations in therapeutic style that may enhance therapeutic progress. However, the applicability of the information needs to be evaluated for each client. The therapist’s task is to help clients identify strategies for dealing with problems within cultural constraints and to develop the skills to negotiate cultural differences with the larger society. To achieve this, the counselor must sometimes be willing to adopt a variety of helping modes, such as advisor, consultant, and advocate.
In summary, errors in assessment can occur because of biases, mistakes in thinking, and stereotypes held by the clinician. In the past, assessment practices focused only on the client; potential counselor biases or inaccurate assumptions were not taken into consideration. It is now clear that effective assessment requires that therapist characteristics also be considered. Do cultural competency guidelines contribute to stereotypes? Some mental health practitioners believe that this is the case. However, we would argue precisely the opposite. If used appropriately, cultural competency and evidence-based practice guidelines that focus on awareness of one’s values and biases, appropriate use of cultural knowledge, and the value of understanding the unique background and experience of each client help prevent stereotyping.
Contextual and Collaborative Assessment
Self-awareness is an important first step in reducing errors in multicultural assessment. However, this is only one part of the equation. Only through close collaboration with the client can we accurately identify the specific issues involved in the presenting problem and eliminate the blind application of cultural knowledge. This is best accomplished with a collaborative approach in which clients are given opportunities to share their beliefs, perspectives, and expectations, as well as their explanations of problems. If a client’s belief about the presenting problem differs from that of the therapist, treatment based only on the therapist’s views is likely to be ineffective. Here we will share some approaches a therapist might use to introduce the assessment and case conceptualization process in a way that facilitates dialogue and a collaborative relationship.
What we are going to do today is gather information about you and the problem that brings you in for counseling. In doing so, I’ll need your help. In therapy we’ll work together to decide what concerns to address and what solutions you feel comfortable with. Some of the questions I ask may seem very personal, but they are necessary to get a clear picture of what may be going on in your life. As I mentioned before, everything that we discuss is confidential, with the exceptions that we already went over. I will also ask about your family and other relationships and about your values and beliefs, since they might be related to your concerns or might help us decide the best strategies to use in therapy. Sometimes our difficulties are not just due to personal issues but are also due to expectations from our parents, friends, or society. The questions I’ll be asking will help us put together a more complete picture of what might be happening with you and what might be causing the symptoms you came here to address. When we get to that point, we can talk together to see if my ideas about what might be going on seem to be on the right track. If there are any important issues I don’t bring up, please be sure to let me know. Do you have any questions before we begin?
Assessment and diagnosis are critical elements in the process of devising a treatment plan. An introduction such as the one just presented helps set the stage for a collaborative and contextual intake interview. Clients are informed that family, environmental, and social-cultural influences will be explored. Many clinical assessments and interviews do not consider these factors and, therefore, must be modified. To remedy this shortcoming, we stress the importance of both the collaborative approach, in which the client and the therapist work together to construct an accurate definition of the problem, and the contextual viewpoint, which acknowledges that both the client and the therapist are embedded in systems such as family, work, and culture. These perspectives are gaining support within various mental health professions. For example, ethical principles regarding informed consent about therapy emphasize the need to give clients the information necessary to make sound decisions and, thus, be collaborators in the therapy process (Behnke, 2004).
The importance of collaboration was also stressed in the report of the President’s New Freedom Commission on Mental Health (2003), in which clients are described as “consumers” and “partners” in the planning, selection, and evaluation of services. As we have already discussed, contextualism is also important: recognizing that both therapist and client operate from their own experiences and worldviews. Just as clients may have socialization experiences or experiences with prejudice or discrimination that play a role in their presenting concerns, therapists may hold worldviews or have had experiences that influence their perceptions of the client or the client’s issues.
Karen Seeley (2004) is a mental health practitioner who describes herself as a “White, middle-class North American therapist.” She recognized that she differed from ethnic minority clients in terms of culture, nationality, race, and personal history and that these differences could inhibit communication in therapy and produce inaccurate assessment. She was also aware that the therapeutic techniques developed for “mainstream Westerners” may be inappropriate in multicultural situations. Hence she strives to use cultural knowledge not as an end in itself, but as a starting point from which to investigate each client’s particular cultural formation and identity. Seeley demonstrates many of the qualities of cultural competence, starting with self-awareness, as illustrated in her work with clients. The following case studies are taken from her work.
Case Study
Diane (as described in Seeley, 2004)
Diane sought treatment when she began to feel emotionally destabilized by the psychological problems of an acquaintance. She worked off campus as the assistant manager of a bookstore and one of her employees had developed a severe eating disorder. Diane had become increasingly distressed as she witnessed the employee’s deterioration. In addition, she began to experience a loss of appetite and became convinced that she, too, was developing an eating disorder. In the intake interview, Diane did not present significant anorexic symptoms. At first glance, she seemed to need help differentiating herself from others. During the second session, Diane expressed even greater emotional distress because her employee had announced that she would be leaving her job to receive treatment for anorexia. Diane shared that she felt responsible for her employee’s condition and explained how she had tried very hard to get her to eat. She felt a great sense of failure when she was unable to do so. In conceptualizing the case, Seeley needed to determine why her client was so distressed and so involved in the employee’s struggles with anorexia. Were Diane’s symptoms the result of obsessive tendencies or were they possibly related to unhealthy identity and boundary aspects of her relationship with her employee? In other words, was the presenting problem an internal (i.e., intrapsychic) phenomenon? Because Diane was an immigrant raised in Samoa, Seeley wanted to entertain the possibility of cultural factors in Diane’s behavior and emotional distress.
Seeley conducted an ethnographic inquiry, asking Diane about work relationships in Samoa, especially between supervisors and employees. Diane explained how the work relationship was “like a family” and how supervisors assume responsibility for the well-being of their employees. When asked how she viewed the relationship with her current employee in Samoan terms, she compared it to a “mother-daughter” relationship. In addition, Diane explained how eating and food are a very important part of social relationships in Samoa, describing how a good host is responsible for making sure that everyone eats and has enough to eat.
With this additional information, Seeley hypothesized that Diane’s feelings of “excessive responsibility” were probably the result of cultural influences rather than obsessive tendencies or boundary issues. When Seeley presented this hypothesis to Diane, she agreed that this could be the cause of her distress about the employee’s welfare. After discovering the roots of her symptoms, Diane began an exploration of the differences in expectations in employer–employee relationships in the United States compared to Samoa. This process helped Diane reduce her feelings of responsibility and distress, with a resultant reduction in depressive symptoms. Seeley’s use of a cultural inquiry allowed her to conceptualize the problem accurately. We believe this case demonstrates a highly effective use of cultural competency guidelines.
Collaborative Conceptualization Model
Case Study
Erica
Erica is a biracial (North American father and Korean mother) college student who was raised in Korea. She sought counseling to relieve feelings of loneliness and anxiety at the university. Erica speaks unaccented fluent English and considers herself bicultural. When asked to describe her background and her current problem, she was reluctant to give much information. The counselor entertained the possibility that cultural constraints might be involved in Erica’s difficulty to talk about mental health issues and inquired about how she would describe her problems in a Korean setting. Erica responded that in Korea people did not convey their problems to others; it would be considered selfish and self-centered. With Erica’s help, the problem was conceptualized as a conflict between Korean norms and values and those of the United States. Erica’s roommates believed she was too “passive and meek” and encouraged her to be more assertive. Erica explained that in Korea people were “tuned into” her needs, so she did not need to directly verbalize them. Erika began to realize that her social anxiety and loneliness were related to differing cultural expectations and concluded that she would need to learn new ways of communicating. (Seeley, 2004)
The preceding example illustrates the importance of collaborative assessment and the value of obtaining clients’ input regarding social and cultural elements that may be associated with their presenting problems. Gambrill (2005) identifies ways in which therapists can enhance the accuracy and effectiveness of assessment, conceptualization, and treatment planning. First, as we have emphasized previously, therapists need to be aware of the impact that their own values, worldviews, and beliefs have on their practice. Similarly, clients’ unique characteristics, values, and circumstances should always be considered. Additionally, clients should be encouraged to actively participate in the assessment and conceptualization process. In other words, case conceptualization, as well as assessment, is best done in a collaborative manner in which therapist self-awareness, client involvement, and the scientific method are all utilized. With this approach, the therapist and the client can choose intervention strategies that involve the integration of high-quality research, clinical expertise, and client input.
Principles of Collaborative Conceptualization
Collaborative conceptualization (modified from Spengler, Strohmer, Dixon, & Shivy, 1995, to include client involvement) consists of the following steps:
1. Use both clinician skill and client perspective to understand the problem. Clinical expertise is essential in assessment, developing hypotheses, eliciting client participation, and guiding conceptualization. Therapists bring experience, knowledge, and clinical skill to this process; clients bring an understanding of their own background and their perspective on the problem. Therapists should be aware of their own values, biases, preferences, and theoretical assumptions and how these factors might influence their work with clients.
2. Collaborate and jointly define the problem. Within this framework, the clinician and the client, either jointly or independently, formulate conceptualizations of the problem. A joint process generally leads to more accurate conceptualization. In cases where definitions of the problem differ, these differences are discussed, and the agreed-upon aspects of the problem can receive primary focus. In some cases, the therapist can reframe the client’s conceptualization in a manner that results in mutual agreement.
3. Jointly formulate a hypothesis regarding the cause of the problem. The therapist can tentatively address possibilities concerning what is causing or maintaining the problem with questions such as “Could the problems you are having with your children be due to the values that they are being exposed to?” “Are you trying too hard to be accepted by society and denying your own identity?” “You mentioned before that you get really down on yourself when you feel you aren’t living up to your parents’ expectations. Do you think that might have anything to do with how you’ve been feeling lately?” or “I remember you saying that it’s been hard to be so far away from others who share your religious background. Do you think that has anything to do with your depression?” When perceptions or explanations of the problem differ, these differences can be acknowledged and an attempt made to identify and focus on similarities.
4. Jointly develop ways to confirm or disconfirm the hypothesis on the problem, continuing to consider alternative hypotheses. The therapist might say, “If your depression is due, in part, to a lack of activity, how would we determine if this is the case?” or “How can we figure out if your parents’ wanting you to get all A’s in college is part of what is going on?” or “What else might be involved in your feeling depressed?”
5. Test out the hypothesis using both the client and the therapist as evaluators. The therapist might ask, “You explored the positive aspects of your identity. Did that reduce your depressive feelings?” or “You mentioned you felt more depressed this week when you were thinking how you were not as good as other people. Do you think that these critical thoughts might be contributing to your depression?” or “It sounds like you were really feeling down after you talked to your parents this week and shared that you had gotten a B on your calculus exam. What do you think that might mean in terms of what is going on with your depression?”
6. If the conceptualization appears to be valid, develop a treatment plan. The therapist might say, “You mentioned you felt better when you spent some time with friends this week. It sounds to me like you confirmed your hypothesis that being alone increases your depression. You also noticed that you tend to spend less time thinking negative thoughts about yourself when you’re around others. Let’s talk about how that important information can be used when we decide how to best treat your depression.”
7. If the hypothesis is not borne out, therapist and client collect additional data and formulate new, testable hypotheses. The therapist might say, “It’s good we checked out that idea that there is a connection between your negative thoughts and being home alone. You mentioned that when you went out walking, you started thinking about the times you’ve been rejected and your depression seemed to get even worse. Can I ask you to share some of the thoughts that were going through your head when you were walking?”
We believe it is of critical importance to go through a collaborative process such as this; therapist and client can adopt a scientific framework as they work to conceptualize the problem and then have an equal voice in evaluating the problem definition. Unless there is substantial agreement on the definition of a problem, therapeutic progress is likely to be less than optimal.
There is a movement away from relying on “practitioners’ ideology” or preferences for treatment options to interventions that have received research support (Edmond, Megivern, Williams, Rochman, & Howard, 2006). As mentioned in our discussion of evidence-based practice in Chapter 9, we believe that intervention strategies should align with facilitating qualities possessed by therapists (empathy, warmth, and genuineness), client characteristics (motivation, personality, and support systems), and research-based therapeutic techniques. Interventions should not be rigidly applied but instead should be modified according to client characteristics and feedback. Consensus between therapist and client regarding the course of therapy strengthens the therapeutic relationship. In addition, using a collaborative approach allows clients to develop confidence that the therapist understands their issues and is using methods that are likely to achieve desired goals. Thus collaboration improves treatment outcome by enhancing clients’ hope and optimism.
Infusing Cultural Competence into Standard Clinical Assessments
Many interview forms and diagnostic systems place little emphasis on collaboration or contextualism. Instead, the traditional medical model is usually followed and diagnosis is primarily made through the identification of symptoms, without attempts to validate impressions or determine the meaning of the symptoms for the client. In this approach, problems are seen to reside in the individual, with little attention given to family, community, or environmental influences.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) acknowledges the importance of cultural influences on diagnoses such as culture-related and gender-related issues for each mental disorder. For effective assessment, determining the cultural context of the illness is “essential.” The “Outline for Cultural Formulation” includes an overall cultural assessment that takes into account the cultural identity of the individual; cultural conceptualizations of distress, psychosocial stressors, and cultural features of vulnerability and resilience; and cultural differences between the individual and the clinician. DSM-5 also contains a Cultural Formulation Interview (CFI) comprising sixteen questions “that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual’s clinical presentation and care” (American Psychiatric Association, 2013, p. 750). Similar mental health cultural assessment forms are also available online (Transcultural Mental Health Centre, 2015). Although DSM-5 has expanded the emphasis on the importance of cultural factors in assessment, most standard intake forms only provide cursory assessment of cultural influences.
Therapists who recognize and value the importance of a collaborative and contextual approach may decide to make modifications in standard assessment intake forms. We will suggest ways in which consideration of cultural and environmental factors can be included in or added to standard intake interviews.
Culturally Sensitive Intake Interviews
Nearly everyone in the mental health field conducts diagnostic intake interviews during the first sessions. Typically, the client is informed that the assessment session is not a therapy session but rather a time to gather information in order get to know the client and more fully understand the client’s concerns. The specific relationship-building skills previously addressed with respect to evidence-based practice (in Chapter 9) are extremely important in the context of assessment as well as therapy. For example, it is important that the clinician ask questions and respond to answers in a supportive and empathetic manner.
Intake forms generally include questions concerning client demographic information, the presenting problem, history of the problem, previous therapy, psychosocial history, educational and occupational experiences, family and social supports, medical and medication history, and risk assessment. Many standard intake questions are focused primarily on the individual, with little consideration of situational, family, sociocultural, or environmental issues. We realize that it is difficult to modify standard intake forms used by clinics and other mental health agencies, but consideration can be given to these contextual factors when gathering data or making a diagnosis. Common areas of inquiry found in standard diagnostic evaluations and the rationale for each area are presented below (Rivas-Vazquez, Blais, Rey, & Rivas-Vazquez, 2001), together with suggestions for specific contextual queries that can be used to supplement the standard interview for ethnic minorities and other diverse populations.
· Identifying information. Asking about the reason for seeking counseling allows the therapist to gain an immediate sense of the client and his or her reason for seeking therapy. Other information gathered includes age, gender, ethnicity, marital status, and referral source. It is also important to inquire about cultural groups to which the client feels connected. Clinicians should also consider whether other areas of diversity, such as religion, sexual orientation, age, gender, or disability, are important in understanding the client or any of the difficulties the client is facing. For ethnic minorities or immigrants, clinicians can inquire about the degree of acculturation or adherence to traditional values. When relevant, ask about the primary language used in the home or the degree of language proficiency of the client or family members. Determine whether an interpreter is needed. (It is important not to rely on family members to translate when assessing clinical matters.)
· Presenting problem. To understand the source of distress in the client’s own words, obtain his or her perception of the problem and assess the degree of insight the client has regarding the problem and the chronicity of the problem. Some questions clinicians can consider include: What is the client’s explanation for his or her symptoms? Does it involve somatic, spiritual, or culture-specific causes? Among all groups potentially affected by disadvantage, prejudice, or oppression, does the client’s own explanation involve internalized causes (e.g., internalized heterosexism among gay males or lesbians or self-blame in a victim of a sexual assault) rather than external, social, or cultural factors? What does the client perceive are possible solutions to the problem?
· History of the presenting problem. To assist with diagnostic formulation, it is helpful to have a chronological account of and perceived reasons for the problem. It is also important to determine levels of functioning prior to the problem and since it developed and to explore social and environmental influences. When did the present problem first occur, and what was going on when this happened? Has the client had similar problems before? How was the client functioning before the problem occurred? What changes have happened since the advent of the problem? Are there any family issues, value conflicts, or societal issues involving such factors as gender, ability, class, ethnicity, or sexual orientation that may be related to the problem?
· Psychosocial history. Clinicians can benefit from understanding the client’s perceptions of past and current functioning in different areas of living, as well as early socialization and life experiences, including expectations, values, and beliefs from the family that may play a role in the presenting problem. How does the client describe his or her level of social, academic, or family functioning during childhood and adolescence? Were there any traumas during this period? Were there any past social experiences or problems with the family or community that may be related to the current problem? McAuliffe and Eriksen (1999) describe some questions that can be used, when appropriate, to assess social background, values, and beliefs: “How has your gender role or social class influenced your expectations and life plans?” “Do religious or spiritual beliefs play a role in your life?” “How would you describe your ethnic heritage; how has it affected your life?” “Within your family, what was considered to be appropriate behavior in childhood and adolescence, and as an adult?” “How does your family respond to differences in beliefs about gender, acculturation, and other diversity issues?” “What changes would you make in the way your family functions?”
· Abuse history. Despite the potential importance of determining if the client is facing any harmful or dangerous situations, many mental health professionals do not routinely inquire about abuse histories, even in populations known to be at increased risk of abuse. In one study, even when the intake form included a section on abuse, less than one-third of those conducting intake interviews inquired about this topic (Young, Read, Barker-Collo, & Harrison, 2001). It is extremely important to address this issue since background information such as a history of sexual or physical abuse can have important implications for diagnosis, treatment, and safety planning. The following questions involve domestic violence for women (Stevens, 2003, p. 6) but can and should be expanded for use with other groups, including men and older adults:
1. Have you ever been touched in a way that made you feel uncomfortable?
2. Have you ever been forced or pressured to have sex?
3. Do you feel you have control over your social and sexual relationships?
4. Have you ever been threatened by a (caretaker, relative, partner)?
5. Have you ever been hit, punched, or beaten by a (caretaker, relative, or partner)?
6. Do you feel safe where you live?
7. Have you ever been scared to go home? Are you scared now?
If during the intake process a client discloses a history of having been abused and there are no current safety issues, the therapist can briefly and empathetically respond to the disclosure and return to the issue at a later time in the conceptualization or therapy process. Of course, developing a safety plan and obtaining social and law enforcement support may be necessary when a client discloses current abuse issues.
· Strengths. It is important to identify culturally relevant strengths, such as pride in one’s identity or culture, religious or spiritual beliefs, cultural knowledge and living skills (e.g., hunting, fishing, folk medicine), family and community supports, and resiliency in dealing with discrimination and prejudice (Hays, 2009). The focus on strengths often helps put a problem in context and defines support systems or positive individual or cultural characteristics that can be activated in the treatment process. This is especially important for ethnic group members and individuals of diverse populations subjected to negative stereotypes. What are some attributes they are proud of? How have they successfully handled problems in the past? What are some strengths of the client’s family or community? What are sources of pride, such as school or work performance, parenting, or connection with the community? How can these strengths be used as part of the treatment plan? Using one’s strengths has been found to lower depression and increase happiness (Gander, Proyer, Ruch, & Wyss, 2013).
· Medical history. It is important to determine whether there are medical or physical conditions or limitations that may be related to the psychological problem and important to consider when planning treatment. Is the client currently taking any medications, or using herbal substances or other forms of folk medicine? Has the client had any major illnesses or physical problems that might have affected his or her psychological state? How does the client perceive these conditions? Is the client engaging in appropriate self-care? If there is some type of physical limitation or disability, how has this influenced daily living? How have family members, friends, or society responded to this condition?
· Substance abuse history. Although substance use can affect diagnosis and treatment, this potential concern is often underemphasized in clinical assessment. Because substance-use issues are common, it is important to ask about drug and alcohol use. What is the client’s current and past use of alcohol, prescription medications, and illegal substances, including age of use, duration, and intensity? If the client drinks alcohol, how much is consumed? Do the client or family members have concerns about the client’s substance use? Has drinking or other substance use ever affected the social or occupational functioning of the client? What are the alcohol- and substance-use patterns of family members and close friends?
· Risk of harm to self or others. Even if clients do not share information about suicidal or violent thoughts, it is important to consider the potential for self-harm or harm to others. What is the client’s current emotional state? Are there strong feelings of anger, hopelessness, or depression? Is the client expressing intent to harm him- or herself? Does there appear to be the potential to harm others? Have there been previous situations involving dangerous thoughts or behaviors? Asking a client a simple question such as “How likely is it that you will hurt yourself?” may yield accurate self-predictions of future self-harm. (Peterson, Skeem, & Manchak, 2011)
Diversity Focused Assessment
Diversity considerations can easily be infused into the intake process. Such questions can help the therapist understand the client’s perspective on various issues. Questions that might provide a more comprehensive account of the client’s perspective include (Dowdy, 2000):
· “How can I help you?” This addresses the reason for the visit and client expectations regarding therapy. Clients can have different ideas of what they want to achieve. Unclear or divergent expectations between client and therapist can hamper therapy.
· “What do you think is causing your problem?” This helps the therapist to understand the client’s perception of the factors involved. In some cases, the client will not have an answer or may present an implausible explanation. The task of the therapist is to help the client examine different areas that might relate to the problem, including interpersonal, social, and cultural influences. However, one must be careful not to impose an “explanation” on the client.
· “Why do you think this is happening to you?” This question taps into the issue of causality and possible spiritual or cultural explanations for the problem. Some may believe the problem is due to fate or is a punishment for “bad behavior.” If this question does not elicit a direct answer or if you want to obtain a broader perspective, you can inquire, “What does your mother (husband, family members, friends) believe is happening to you?”
· “What have you done to treat this condition?” “Where else have you sought treatment?” These questions can lead to a discussion of previous interventions, the possible use of home remedies, and the client’s evaluation of the usefulness of these treatments. Responses can also provide information about previous providers of treatment and the client’s perceptions of prior treatment.
· “How has this condition affected your life?” This question helps identify individual, interpersonal, health, and social issues related to the concern. Again, if the response is limited, the clinician can inquire about each of these specific areas.
Implications for Clinical Practice
Although there is increased focus on cultural competence in assessment, difficulties in effective implementation of culturally competent practices are prevalent. Hansen et al. (2006) conducted a random sample survey of 149 clinicians regarding the importance of multicultural competencies and, more importantly, whether they practiced these recommendations. Although the participants rated competencies such as “using DSM cultural formulations,” “preparing a cultural formulation,” “using racially/ethnically sensitive data-gathering techniques,” and “evaluating one’s own multicultural competence” as very important, they were much less likely to actually use these competencies in their practice.
What accounts for this discrepancy between the ratings of importance of multicultural competencies and the actual use of recommended practices? We believe that a contributing factor is the continued reliance on counseling and psychotherapy practices that were developed without consideration of diversity issues or the impact of therapist qualities on assessment and conceptualization. Many intake interviews and clinical assessments continue to reflect the view that a disorder resides in the individual. Until assessment questionnaires systematically include specific questions such as those discussed in this chapter, cultural competency will receive only lip service.
Knowledge of cultural variables and sociopolitical influences affecting members of different groups can sensitize therapists to possible cultural, social, or environmental influences on individual clients. As you read the remaining chapters in this text, which deal with a variety of specific populations, we hope you do not see the information as an end in itself, but rather as a means to assist you to create hypotheses when working collaboratively with clients in the assessment and conceptualization process. As we advise repeatedly throughout the chapters, it is important not to stereotype clients or overgeneralize based on the information presented. Inappropriate reliance on cultural information can lead to misdiagnosis and mistaken treatment recommendations such as seeking treatment with a folk healer. Such problems can be minimized by combining cultural and traditional psychiatric or psychological assessments (Paniagua, 2013).
In the following chapters on diverse populations, we present various characteristics, and strengths of each population, specific challenges of working with them, and implications of these factors for clinical practice. It is our hope that you will refer back to this chapter for guidance as you strive to implement culturally competent practices with clients from these specific populations.
Summary
Accurate assessment, diagnosis, and case conceptualization are essential for the provision of culturally appropriate treatment. Most clinicians recognize that socioeconomic status, gender, and racial/cultural background play an important role. Counselors often forget that their own beliefs, values, theoretical assumptions, and other biases can affect clinical judgment. Contextual and collaborative assessment, which infuses cultural factors into standard intake and assessment procedures and takes into consideration the client’s unique personal and cultural background, can reduce diagnostic errors.
Assessment is influenced by both client and therapist variables. Clinicians should be aware of the influence of stereotypes, and remain alert for common diagnostic errors. Such errors include (a) confirmatory strategy—searching only for evidence or information supporting one’s hypothesis; (b) attribution errors—holding a different perspective on the problem from that of the client; (c) judgmental heuristics—using quick-decision labels or automatic associations; and (d) diagnostic overshadowing—minimizing the client’s actual problem by attending primarily to other salient characteristics such as age, ethnicity, or sexual orientation as causal factors. We are all susceptible to making errors and it is important to adopt a tentative stance and test out our observations.
Culturally competent assessment involves self-awareness, knowledge of culturally diverse groups, specific clinical skills, and the ability to intervene at the individual, group, institutional, and societal levels. This process works best with a contextual and collaborative approach, acknowledging that both the client and the therapist are embedded in systems such as family, work, and culture, and working with the client to develop an accurate definition of the problem, the appropriate goals, and effective interventions. Steps involved with collaborative assessment include (a) using both clinician skill and client perspective to understand the problem; (b) jointly defining the problem; (c) working together to formulate and evaluate a hypothesis on the cause of the problem; (d) confirming or disconfirming the hypothesis; and (e) developing a treatment plan.
Standard clinical assessment forms need to account for the cultural identity of the individual, cultural conceptualizations of distress and appropriate treatment, psychosocial stressors, and any cultural differences between the individual and the clinician. These diversity considerations can easily be infused into the intake process.
Glossary Terms
Attribution errors
Collaborative approach
Collaborative assessment
Collaborative conceptualization
Confirmatory strategy
Contextual viewpoint
Culturally competent assessment
Culturally sensitive intake interviews
Diagnostic overshadowing
Ethnographic inquiry
Judgmental heuristics
Stereotypes
Therapeutic alliance
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