Issues of Culture in Psychiatric
Assessment and Treatment
Carmela Pérez, PhD
Clinical Coordinator,
Latino Mental Health Program
Behavioral Health Services
SVCMC
Importance
• Being culturally competent improves the care we
provide to all patients.
• There is overwhelming evidence of the
underutilization of mental health services by
“minority” cultural groups.
• “Minority” groups are becoming majority- e.g.
Latinos as fastest growing ethnic minority in US.
Estimated that by 2050 Latinos will comprise 25%
of US population
Latino Underutilization and
Views Towards Mental Health
• Research consistently finds that Latinos underutilize
mental health services
• Specifically, findings suggest close to 40% lower
probability of using outpatient/ambulatory psychiatric
services as compared to Euro-Americans
• Conversely, Latinos have been found not only overrepresented on inpatient wards as compared to EuroAmericans, but also admitted for longer periods of
time (Latinos= 5days; Euro-Americans= 3 days)
Objectives
• To better understand culturally competent
psychiatric care
• To learn about using a cultural formulation in
psychiatric assessment
• To be aware of the impact of culture in the
psychiatric treatment -- e.g. Latinos
What is Cultural Competence?
(American Academy of Family Physicians, 2000)
• A set of congruent behaviors, atttitudes and policies that
come together as a system, agency or among
professionals and enable that system, agency, or those
professionals to work effectively in cross-cultural
situations.
• The word “culture” is used because it implies the
integrated pattern of human thoughts, communications,
actions, customs, beliefs, values and institutions of a
racial, ethnic, religious, or social group.
• The word competence is used because it implies having
a capacity to function effectively.
Cultural Competence
• 2 Approaches
– Can occur in the context of being able to work
with various cultures;
– and/or with one specific cultural group
Challenges to Cultural Competency
• Recognition of clinical differences among people of
different ethnic and racial groups
• Communication-- verbal, body language
• Ethics-- Respect for belief systems of others and
effects of these belief systems on well-being
• Trust-- Many patients wary of authority figures and
the care we provide for good reasons
• Realization that we do not have all the answers
Levels of Cultural Competence
• Systems level (Government, Policy)Includes guidelines for delivery of service;
hiring staff; access to care
• Agency level (Hospital, Community
Services)- Developing programs for
ethnically diverse patients
• Individual therapist level- What we do as
individual treaters
The Culturally Competent Therapist
• Being a Good General Therapist- Asking extra
questions about culture
• Dynamic Sizing- Knowing when to
individualize and when to generalize
(distinguishing whether cultural issues play a
role in the patient’s problems or not)
• Ethnic Specific Knowledge/UnderstandingUtilizing culturally appropriate skills and
attitudes in treatment
Problems in Cross-Cultural
Diagnosis
• Missing the diagnosis entirely
• Underdiagnosis/ Overdiagnosis -Inaccurate assessment of the severity of a
disorder
• Mistaken diagnosis
Psychiatric Assessment
Across Cultural Boundaries
• The Clinical Interview
• Mental Status Examination
• Cultural Formulation-- DSM IV
The Clinical Interview
• Establishing trust and open communication
• Facilitation-- Allowing (letting the patient warm up), and
guiding the patient to report signs, symptoms, and perceived
problems (Remember many ethnic minority patients report
somatic symptoms as presenting problem)
• Clarification-- Crucial for orienting the therapist to the nature of
the problem and its psychosociocultural context. (May need to
use a Cultural Broker or Translator- friend or relative of the
patient who can help to clarify whether the patient’s ideas,
behaviors, and emotional responses are culturally congruent,
idiosyncratic, bizarre, etc.)
Mental Status Examination
• Appearance and behavior-- Errors in
observation may originate because the
observer is unfamiliar with normal vs
abnormal appearances in a particular culture
• Remember Fund of Information greatly
determined by level of education and SES
• Careful with importance attributed to
proverbs, which also do not translate across
cultures
Cultural Formulation-- DSM IV
• Supplements DSM IV multiaxial diagnoses
• Provides a systematic review of the individual’s
cultural background, the role of the cultural
context in the expression and evaluation of
symptoms and dysfunction, and the effect that
cultural differences may have on the relationship
between the individual and the therapist
Cultural Formulation-- DSM IV
• Cultural identity of the individual
• Cultural explanations of the individual’s illness
• Cultural factors related to psychosocial
environment and levels of functioning
• Cultural elements of the relationship between the
individual and the clinician
• Overall cultural assessment and diagnosis and
care
Cultural Formulation-- DSM IV
• Cultural identity of the individual
– Individual’s ethnic or cultural reference groups
– Language abilities, use, and preference
(including multilingualism)
– For immigrants and ethnic minorities, note
separately the degree of involvement with both
the culture of origin and the host culture (Phase
of Cultural Transition they are at)
The Phases of Cultural Transition
• Immediate Phase or Arrival
– Exitement and euphoria
– Disorganization
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Suspiciousness, Distrust, and Paranoid Tendencies
Lack of differentiation of nonself from self
Depression and anxiety
Psychosomatic symptoms
• Integration-Disintegration
• The Therapist as Cultural Intermediary
Cultural Formulation-- DSM IV
• Cultural explanations of the individual’s
illness
– Predominant idioms of distress through which symptoms or the need for
social support are communicated (e.g., “nervios”, possessing spirits,
somatic complaints, inexplicable misfortune, God’s way)
– The meaning and perceived severity of the individual’s symptoms in
relation to norms of the cultural reference group, and any local illness
category used by the individual’s family and community to identify the
condition)
– The perceived causes or explanatory models that the individual and the
reference group use to explain the illness, and the current preferences
for and past experiences with professional and popular sources of care
Cultural Formulation-- DSM IV
• Cultural factors related to psychosocial
environment and levels of functioning
– Cultural-relevant interpretations of social stressors;
available social supports
– Levels of functioning and disability
– Includes stresses in the local social environment, and
the role of religion and kin networks in providing
emotional, instrumental, and informational support
Cultural Formulation-- DSM IV
• Cultural elements of the relationship
between the individual and the clinician
– Differences in culture and social status between the
individual and the clinician
– Problems that these differences may cause in diagnosis
and treatment (e.g. difficulties in eliciting symptoms or
understanding their cultural significance, in negotiating
an appropriate relationship or level of intimacy, in
determining whether a behavior is normative or
pathological)
Cultural Formulation-- DSM IV
• Overall cultural assessment and
diagnosis and care
– The formulation concludes with a discussion of
how these cultural considerations specifically
influence comprehensive diagnoses and care
Approaches to the Treatment of
Ethnic Minorities
• 2 Approaches generally used:
– Knowledge about a particular culture gained in the
absence of direct experience with patient-- Runs risk of
being highly intellectualized, often stereotyped
information that has been found not to translate into
therapeutic action
– Technique-oriented approaches-- Making specific
changes in technique based on needs and values of a
specific cultural group (e.g. Achieving credibility early
in treatment (1st session))
Achieving Credibility with the
Ethnic Minority Patient
• Patients have expectations and ideas about
treatment and our role
• Importance to be able to achieve credibility- meet the patient where they are
• Ethnic-minority patients have been found to
underutilize, and terminate prematurely
from, mental health services
Major areas for Achieving
Credibility
• Conceptualization of problem
• Means for problem resolution
• Goals for treatment
Achieving Credibility- Goals for
the 1st session
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Anxiety reduction
Relief from distress
Cognitive clarity
Normalization
Reassurance
Hope, faith
Skills acquisition
Coping perspective
Goal-setting
Latino Values, Interpersonal
Relationships and Coping
Mechanisms, and Alternative
Support Systems and their Impact
on Psychiatric Treatment
La Familia Latina: Close and
Extended Kin
• FAMILISMO-- Connectedness
• Collective sense of self
• The treater as part of the “FAMILIA”
Etiology of Psychiatric Illness:
Stigma
• Mind & Body Connection: llness as having
roots in physical imbalance
• Illness caused by social indiscretion
• Illness as manifestation of one’s standing
with God
• Illness attributed to evil or magical forces
Interpersonal Relationships and
Coping Mechanisms
• RESPETO and PERSONALISMO
• INDIRECTAS Y DICHOS--”Indirect
communication”
• AGRADECIMIENTO, CONFIANZA, Y
SIMPATIA
• Coping Mechanisms
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FATALISMO
CONTROLARSE
AGUANTARSE
SOBREPONERSE
Alternative Support Systems
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Alternative Resource Theory
BOTANICAS
ESPIRITISMO
SANTERIA
Impact on Delivery of Psychiatric Services
• As a result, the Latino patient has a complex set of
therapeutic expectations that involve: psychological,
emotional, physical (medications), and environmental
interventions
• The stigma of “El Loco”: Latino patients are reluctant
to seek psychiatric services for any mental health
problem because of generalization with “Locura”
• Expect intermittent treatment- it should not be a
surprise to us that psychotherapy, especially in the
early phases of treatment, is not a priority particularly
since it is not highly valued by Latinos