Chapter 4
Impact of Race, Ethnicity, and Culture
on the Expression and Assessment of
Psychopathology
Multicultural Competency
The relevance of ethnicity in adult
psychopathology has been substantiated by
identifying disparities in:
• Prevalence rates
• Symptom presentation
• Mental health service utilization across
diverse ethnic groups
Ethnic Identity and Acculturation
• Ethnic identity is influenced by a person’s:
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Identification as a member of an ethnic group
Sentiments and evaluations of the ethnic group
Self-perception of their group membership
Knowledge and commitment to the group
Ethnic-related behaviors and practices
• Acculturation has traditionally been defined as the extent
to which ethnic minorities adopt the values and
participate in the traditional activities of the mainstream
culture
• Recent reconceptualizations of the acculturation process
utilize a multidimensional approach
Sociocultural Factors
• Important sociocultural contributors to the mental
health of ethnic minorities:
- Socioeconomic status
- Stressful life events
- Ethnic background
- Age cohort
Cross-Cultural Measurement
Equivalence
• Some guidelines for determining equivalence:
– Linguistic or translation equivalence
• The accuracy of the translation and whether diverse
individuals have a similar understanding of words or
phrases used in the instrument
– Conceptual equivalence
• Whether the underlying construct holds the same
meaning across groups
– Psychometric equivalence
• Whether the instrument measures the same attribute
among people from different groups
Multicultural Versus Ethnocentric
Perspective to Assessment
• Multiculturalism: Recognition of equality of
various cultural groups and the right of
individuals to follow their own specified path
• Ethnocentrism: Cognitive bias that supports
judgment about other ethnic, national, and
cultural groups from the observer’s
perspective
Factor Patterns in Ethnic Minorities
• In studies that examine factor patterns across
racial and ethnic minority groups, structural
equation modeling (SEM) is used to examine
relationships among variables while
controlling for measurement error
• Investigators often use this approach when
evaluating equivalence of commonly used
assessment tools for use with minorities
Symptom Expression and Diagnosis
• The current diagnostic system assumes some
commonalities across symptom clusters
• Research defining those symptom clusters was largely
based on European American individuals
• Diagnostic descriptions may not capture experiences of
psychological distress by individuals from nondominant
cultures
• Symptoms linked to pathology in dominant individuals may
not be indicative of pathology for individuals from
nondominant cultures
Cultural Concepts of Distress
• Susto is a Latin American folk illness attributed
to a frightening experience, thought to involve
“soul loss” as part of this culture-bound
syndrome (similar to PTSD)
• Koro is uncommon in Western cultures but
involves anxiety over the possibility of one’s
genitalia receding into the body (OCD)
• Shenjing shuairuo (neurasthenia) involves a
depletion of vital energy (MDD)
Somatization Across Cultures
• Somatization is common across all cultures; however,
the type and frequency of bodily symptoms
expressed may vary
• Higher level of stigma associated with mental illness
in ethnic minorities
• More holistic conceptualization of the person, and
less distinction between mind and body among
ethnic minorities
Racism and Discrimination
• In the United States, racial discrimination is
highest in African Americans, followed by
Asian Americans and Hispanic Americans
• Perceived discrimination has been found to be
negatively correlated with mental health; this
effect appears to be strongest for Asian
Americans (followed by Hispanic Americans
and African Americans)
Influence of Language
• Another influence on symptom expression is the
language used by clinician and client
• There is a tendency for clinicians to rate Latino
clients speaking Spanish or Spanish and English as
having more severe psychopathology and as
functioning less well than Latino clients speaking
English only
Stereotypes and Biases
• The ideology that different ethnoracial groups
should all be treated the same, without regard to
cultural differences, is known as the colorblind
approach
• Multiculturalism embraces differences, strengths,
and uniqueness of each cultural group
• Generalizations about people used as a means of
explaining and justifying differences between
groups and using these differences to oppress a
group is called pathological stereotyping
Symptom Expression and Diagnosis
• Psychotic disorders are often overdiagnosed among
African Americans and others, when a diagnosis of
depression (or no diagnosis) may be more accurate
• Some aspects of hallucinations are culturally
determined:
– The definition of the experience as pathological or not
– The sensory modality through which they are most
commonly experienced
Mistrust of Medical Institutions
• Tuskegee Study: “Special free treatment” for
untreated syphilis in African American males
• Actually performed spinal taps without
anesthesia
• No informed consent
• Active treatment withheld
• Led to the National Research Act in 1974,
which mandated IRB approval
Lack of Awareness—Misdiagnosis
• “Gold standard” assessment measures
• Diagnostic criteria based on European
Americans
• Lack of multicultural training
• Stereotypes affect clinician judgment
• Poor therapeutic alliance due to lack of
cultural awareness
Over-/Underdiagnosis of Minorities
• African Americans and Hispanic Americans are
often overdiagnosed with psychotic disorders and
underdiagnosed with mood disorders
• Healthy cultural paranoia is a term used to
describe a defensive posture taken by African
Americans when approaching a new situation
that could involve racism or discrimination
• Negative stereotypes dictate that drug users are
largely Black and Hispanic, which is not true!
Summary
• Professionals must be cognizant of cultural
factors and the impact on mental health
• Ethnoracial minorities make up 36.6% of the
U.S. population and account for 50.4% of all
births
• Non-Hispanic Whites are projected to be
minority by 2050