Cultural Assessment

Clinical Trainings – ADMHS

Elisa A. Gottheil PhD
Consultants: Cultural Competence A.T.
 Is race a valid construct?

• No… we know now that…

• Race as a cultural identification edge is not
biologically or scientifically valid.
 Then why do we use the term?
• American Anthropological Association, their
statement on "Race“ (May 17, 1998)
http://www.aaanet.org/stmts/racepp.htm
• Why we still use race and ethnicity in state and
federal population analysis (2010):
http://
www.doh.wa.gov/Portals/1/Documents/5500/Race
EthnGuidelines.pdf
 Why do we keep the construct alive in our
clinical assessments?
• Because we still operate in our daily lives
within the construct of race, and reality is
defined by our perception… and…
• Racism can exacerbate many psychiatric
disorders, contributing to poor outcome, and
racial biases can affect diagnostic assessment.
What Races Are There?

1. Black
2. Caucasian/White
3. Mongoloid/Asian
 So what about ethnicity… ?
Ethnicity may be self-assigned or attributed by
outsiders and …
May be rooted in common:
• history
• Geography
• Language
• Religion
• Other shared characteristic of the group
Hispanic compared with Non-Hispanic in USA
 What will our cultural landscape look like in
2050?
• By the year 2050, it is projected that close to
50% of the U. S. population will be of biracial,
multiethnic or multiracial heritage (U.S.
Census Bureau).
https://www.census.gov/prod/www/population.html#forborn
• And what about other diversities?
• …. Mind boggling…
 What is culture after all… according to the
DSM 5…
• Systems of knowledge,
• Concepts,
• Rules and
• Practices that are learned and
transmitted across generations.
 Relevance of Culture in the Work We Do
• Culture shapes
– which symptoms are expressed
– how they are expressed
• Culture influences
– meaning given to symptoms
– what society deems appropriate or inappropriate
– conceptualization & rationale of psychiatric diagnostic
categories or groupings
– matrix for clinician/client exchange
 Culture? Ethnicity? and…
• We can choose to identify each family as a
culture in itself, resulting from the confluence
of tensions of cultures that interact with that
family’s own
– Systems of knowledge,
– Concepts,
– Rules and
– Practices that are learned and transmitted across
generations.
 You may want to watch:
https://www.youtube.com/watch?v=x1RzlXXhg4w
21 minutes video

How an American born young woman, fourth

generation German immigrants, self-assesses
culturally. Worth watching for defining elements.
 Hays and the ADDRESSING Model
• Article in your handout
• The ADRESSING model can be used to challenge
one’s biases through the consideration of a
particular ethnic identity in relation to all of the
other ADRESSING influences.
• By looking at the within-group differences
corresponding to each of the ADRESSING Factors,
the tendency to make inaccurate generalizations
is reduced.
Cultural Factor Minority Group Biases w Power Specializations

AGE/GENERATIONAL Older Adults Ageism Geropsychology

DISABILITY People with Disabilities   Rehabilitation

Counseling

RELIGION Religious Minorities    

ETHNICITY/RACE Ethnic Minorities Racism Multicultural

Counseling &
Psychotherapy
SOCIAL STATUS People of Lower Status Classism  

SEXUAL ORIENTATION Sexual Minorities Heterosexism Sexual Minorities

Counseling

INDIGENOUS HERITAGE Native Peoples Racism Counseling and

Religion

NATIONAL ORIGIN Refugees, Immigrants, Racism and Multicultural

and International Colonialism Counseling &
Students Psychotherapy

GENDER Women Sexism Feminist Therapy

 Possible Questions Cultural Factors
Clinical Assessment
• Would you describe yourself for me—both how you
see yourself and how you think others see you?
• What were/are the values upheld by your family
and community?
• How has your upbringing affected your worldview?
• What was it like to grow up as a girl/boy in your
family of origin?
• What were the expectations for you in your culture
of origin?
• What does it mean for you to be (definitions given
by client) living in the USA?
 Demand Characteristics
of the Cultural Assessment
• How you see the client will be defined by the
demand characteristics of the assessment
situation
 In Practice…
Client is a middle aged woman, who came from Mexico
in her early thirties, to follow her husband who had
come to California some years earlier. She is from the
South of Mexico, a poor rural village, was raised Catholic,
by strict parents who used physical punishment as
discipline. She worked from an early age and attended
only grammar school. She came to you because she says
she does not want to live anymore, but has made no
attempts. Her children are having problems in school and
the family is seeing a family counselor. She has practiced
the art of curanderism since her early twenties and
continues to do so in the USA.
 In Practice…
How would this client describe herself
differently with
• A counselor who is from the same area and
SES
• A USA counselor who is unaware of the
culture in that part of Mexico.
 DSM 5 Cultural Formulation
• Section III, Emerging Measures and Models
• Pages 749-757; in your handout
• Formats:
– Cultural Formulation Interview (CFI)
– CFI Informant Version (in your handout)
– Supplementary Modules
Find at:
http://
www.psychiatry.org/practice/dsm/dsm5/online-asses
sment-measures#Cultural
The Cultural Formulation Interview
• 16 questions (plus one on the interview); any
patient, any setting. Applicable particularly in:
– cases of social and cultural differences
– difficulties evaluating symptoms
– difficulties evaluating severity and impairment
– disagreement over course of care
– limited engagement in treatment
 Cultural definition of the problem

1. What brings you here today?

Invites further information and probing of:

- the patient’s view
- the patient’s illness/presentation understanding
- cultural and contextual factors
 Supplementary Modules
The supplementary modules are used to expand on the 16
questions.:
1. Explanatory Model
2. Level of Functioning
3. Older Adults
3. Social Network
4. Caregivers
5. Psychosocial Stressors
6. Religion and Spirituality
7. Immigrants and Refugees
8. Cultural Identity
9. Coping and Help Seeking
10.Clinician Patient Relationship
 The Outline for a Cultural Formulation

May be a method to:

- improve cultural awareness in clinical psychiatric
diagnosing
- gain an insight in patients’ meanings and context
related to illness
- improve the diagnostic evaluation

Gaw, A. (2001). The Concise Guide to Cross-Cultural Psychiatry. Washington, D.C.: American Psychiatric Publishing.
 Cultural Formulation DSM 5
• Check your handouts.
• Let’s review the form…
 Cultural Formulation DSM 5
Experience the CF:
• With another participant
• Check the vignette in your handouts
• One of you will be the client
• Take the next 10 minutes to assess your client
according to the vignette
• You may choose to do a cultural assessment
of a client you know well.