C ultural Considerations Introduction to Dx and Tx

1. Cultural ConsiderationsIntroduction to Dx and Tx Class 4

2. 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?

3. 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

4. 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

5. 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.

6. 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.

7. 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

8. 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 syndromes • Clinical judgment is vital to ensuring clients are not over- or under- diagnosed.

9. 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

10. 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

11. 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

12. 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

13. 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 Tx • Provisional 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

14. Sample DSM Diagnosis 300.02 Generalized Anxiety Disorder 300.4 Persistent Depressive Disorder, With Anxious Distress, Mild (Provisional) V62.29 Other Problem Related to Employment Diabetes, type II (per patient report)

15. Sample DSM Diagnosis 301.83Borderline Personality Disorder 305.00 Alcohol Use Disorder, Mild V61.10 Relationship Distress With Spouse or Intimate Partner V62.29 Other Problem Related to Employment

16. 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

17. 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.

18. 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.

19. Considerations for Creating Tx Plan • Diagnostic certainty • Urgency of Tx • Prioritize problems • Prioritize problems that could lead to physical harm to client or someone else or to a decline in client’s medical status • Client resources • Contraindications • Consideration of all feasible Tx modalities • Ensure integration of Dx and Tx choices

20. 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

21. 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

22. Social Interventions Vocational rehabilitation Social Skills training Education of family Placement in a facility (acute, intermediate, chronic) Involuntary commitment Conservatorship Interaction with community agencies/resources

23. DO A CLIENT MAP Diagnosis Objectives of Tx Assessments Clinician Characteristics Location of Tx Interventions Emphasis of Tx Numbers Timing Medications Adjunct Services Prognosis

24. 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