Cultural Considerations in Defining Abnormal Behavior: Implications, Biases, and Reduction Strategies

1. COUN 5480 Cultural considerations

2. Discussion • What is abnormal? • Who defines abnormal? • List implications of medicalizing and psychologizing behavioral and emotional distress.

3. Discussion • Who decides what goes in DSM? • Can science ever be objective? • How do diagnoses perpetuate societal views?

4. Why attend to culture? • Risk becoming “agents of social control” • “Practitioners … tend to label any deviations that they find upsetting or repellant as pathological solely because they trouble the practitioner” (Eriksen & Kress, 2005). • REACTIONS? EXAMPLES?

5. History and current experiences of abuses

6. Why attend to culture? • Tendency to overdiagnose, misdiagnose, underdiagnose • Experiences with status / isms • Not all “diverse” present with same • Language/communication style influences • Our stereotypes play role

7. Problems with the DSM • Inaccurate with diverse populations • People of color excluded from dev • Locates problem in individual • Lack of culture-specific syndromes or culture-bound syndromes related to macrolevel issues • Culture affects perceptions of reality

8. Sources of diagnostic bias • Diagnostic sampling bias • Diagnostic assessment bias • Stereotyping • Data availability and vividness • Self-confirmatory bias • Self-fulfilling prophecy • Diagnostic criterion bias

9. Diagnostic sampling bias “Significant differences between a particular diagnostic sample and the population it is taken to represent” • e.g., Assumptions about PTSD and Veterans when only look at VA • e.g., Assumptions about ADHD bx when only observe in MD office

10. Diagnostic assessment bias “Flaws in gathering or processing clinical information lead to misdiagnosis” • Problems assigning criteria • Use subset • Assign even when criteria are not met • Human information processing errors

11. Diagnostic assessment bias:Stereotyping Automatic decisions based on cognitive schemas. Decide based on clinical stereotypes. • e.g., believe women’s relationship patterns are unhealthy  see complaints as indicative of BPD or DPD

12. Diagnostic assessment bias:Data availability & vividness “Categorizing based on familiarity, ease of recall, or salience” • Some criteria easier to remember  diagnostic overshadowing • Primacy effects • e.g., Remember and use 6 of 9 depression criteria

13. Diagnostic assessment bias:Self-confirmatory bias “Focusing only on confirmatory information” • Have a “hunch” and check it out • Forget about rule-outs • e.g., check out schizophrenia criteria but don’t assess substance use

14. Diagnostic assessment bias:Self-fulfilling prophecy Act on expectation in a way that confirms it. • e.g., Rosenhan’s (1973) experiment • e.g., Assume  respond differently  client responds

15. Diagnostic criterion bias Criteria are “more valid for one group than for another” • “White male standard of adjustment” • Neglect social challenges

16. Reducing bias(McLaughlin, 2002) • Consider the source • Pay attention to work setting influence • Focus on the atypical • Use your criteria • Consider co-morbidity • Do differential diagnosis

17. Reducing bias • Use sign/symptom checklist as standard ax • Make balance sheet of pros and cons • Use other assessment measures • Make expectations explicit • Keep social factors in mind • Be ethical • Get training related to diversity

18. Back to a focus on culture

19. 6 effects of culture:Pathogenic • Culture direct cause of psychopathology • Woman must give birth to son  Anxiety • Pressures regarding “success”

20. 6 effects of culture:Pathoselective • People in culture select particular ways of expressing emotional pain • Running amok • Bereavement • Physical symptoms • Suicide • Violence

21. 6 effects of culture:Pathoplastic • How sxs are manifested varies by culture • Content of phobias, obsessions, delusions • Exaggerated in some • Absent in others

22. 6 effects of culture:Pathoelaborating • Cultural factors contribute to the frequent occurrence of certain mental disorders • Influences on general life patterns • Prevalence of suicide • Prevalence of substance use

23. 6 effects of culture:Pathoreactive • Cultural factors affect understandings and beliefs about the disorder, how react, and how express suffering • Experience of PTSD depends on reaction: • Empathy • Benefits • Ignored

24. Into practice…DSM Cultural formulation • Cultural identity of individual • Reference groups • Degree of involvement • Language • Religious beliefs • Education, employment • Social status, social relations, gender roles • Media usage, identity models

25. Into practice…DSM Cultural formulation • Cultural explanations of illness • How communicate distress • Meaning of sxs • Perceived severity of sxs • Perceived causes • Previous experiences

26. Into practice…DSM Cultural formulation • Psychosocial environment & functioning • Interpretations of social stressors • Available supports • Spiritual • Family / kin • Community • Work • Stigmas

27. Into practice…DSM Cultural formulation • Counselor-client relationship • Differences in status • Differences in culture • Differences in language, understanding

28. Practice considerations • Increase emphasis on Axis IV • Increase personal awareness • Collaborative dx and tx • Use culturally sensitive skills