DSM and Multiculturalism
The DSM isn’t an innocent guide to mental health.
After framing general concerns about cultural competency and diagnosis, Victoria E. White Kress et al. (2005) identify three “controversies and criticisms” regarding the DSM: definitions of normalcy, the objectivity of science, and cross cultural viewpoints. Each of these can be restated as assertions in the following forms: the DSM assumes what is normal, DSM assumes it’s methods provide descriptive objectivity, and the DSM assumes particular cultural demographic. Kress argues that these assumptions negatively affect assessment, diagnosis, and practice. Kress suggests six correctives to help counselors compensate for these negative affects so that they do not over-, under-, or misdiagnose their patients. They include knowing the strengths and weaknesses of the DSM, conducting comprehensive and culturally sensitive assessments of all clients, focusing more energy on Axis-IV diagnosis, increasing one’s personal awareness of cultural bias, engaging in collaborative diagnosis and treatment, and relating to clients in culturally sensitive ways (2005). Let’s look at each of these briefly.
Thorough knowledge of the DSM can help clinicians avoid diagnostic shortcomings because a thorough knowledge of the DSM recognizes that its syndromes are “culture bound” (Kern, 2005). Knowing as much can motivate a more thorough investigation of the patient’s experience, raise awareness of both clinician’s and patient’s cultural biases, and highlight psycho-social environmental factors that may be contributing to symptom formation. Such knowledge can greatly decrease the likelihood of mis-diagnosis.
Kress also provides helpful pointers for completing a thorough and sensitive cultural assessment, which happens when clinicians learn about a patient’s cultural schemas, worldview, cultural identity, sources of relevant cultural information, cultural meaning of patient’s problems and symptoms, impact and effects of family, work and community on the patient, and the patient’s internalized stigmas that are associated with the problem. Kress indicates that “emotions connect with culture at three stages – the client’s initial appraisal of the meaning of an event, his or her emotional feeling, an his or her behavioral response – and that these will all be based on culturally determined norms and roles… different symptoms denote varying issues in different cultures. An accurate assessment of emotion or behavior, therefore, is not possible without an assessment of cultural schemas” (p. 100, 2005). An assessment that thoroughly investigates these cultural schemas can curtail the likelihood of under-diagnosis.
Increased emphasis on Axis IV diagnosis can mitigate over-diagnosis and mis-diagnosis because Axis IV attends to the way “psychosocial and environmental problems often affect the diagnosis, treatment, and prognosis of Axis I and II disorders” (p. 102, 2005). As cultures multiply and fracture within a growing population that still privileges patriarchal, racist, hetero-normative, and classist ideologies, emphasis on Axis IV remains crucial for accurate diagnosis.
The importance of counselor personal awareness cannot be overstated if one wants to avoid misdiagnosis (Kress, 2005). Sensitivity and empathy toward one’s own cultural biases and prejudices are essential for sensitivity and empathy in patient diagnosis and treatment. Personal awareness of this kind is necessary for working with even the most elementary defenses such as projection and introjection, and the handling of transference and counter-transference cannot take place without it. Ignorance may be bliss in some circumstances, but in the therapeutic moment it is dangerous, negligent, and often unethical.
One can further increase their sensitivity and accuracy to diagnostic congruities and incongruities through collaborative assessment, diagnosis and treatment, and this can ensure that patients are not over-pathologized (Kress, 2005). Collaboratively developing diagnosis, goals, and methods for reaching those goals with patients can strengthen therapeutic alliance, motivate patients, and facilitate cultural awareness for both clinician and patient.
Finally, culturally sensitive interpersonal skills that attend to cultural norms and practices can increase both clinician and patient understanding of the problem (Kress, 2005). Clinicians who are able to adapt to and enter their patient’s communication habits, practices, and norms will more likely accomplish Kress’ first five correctives, and thus avoid over-, under,- and misdiagnosing patients- regardless of their cultural heritage.
Kress’ suggestions seem helpful indeed, though I would like to pose the following questions to further the discussion around cultural competency and DSM diagnosis. Due to space constraints, I’ll only list them.
1. Is Kress’ perspective free of the ideological concerns he cites? Some argue that multiculturalism is one of today’s ideologies par excellence. Many European nations, for example, understand acculturation and integration as a necessary condition for the stability and maintenance of culture and the success of their immigrants. Conversely, they argue that multiculturalism actually functions to erode cultural identities. Another way of saying this is that only the west is concerned with multiculturalism, and so might the imposition of multiculturalism be ethnocentric? How multicultural is America’s multiculturalism if it can’t contain many of Europe’s dominant perspectives on culture?
2. Given that assessment and diagnosis must take place in relatively short amounts of time, how does one accomplish Kress’ suggested steps to avoid over-, under-, and misdiagnosis in such short periods of time?
3. How might Kress’ suggestions fit within an analytic topography that emphasizes the importance of defense mechanisms? That is, does Kress’ position too optimistically represent patient transparency and awareness?