The DSM-IV-TR and Culture

Assessment & Diagnosis
The DSM-IV-TR and Culture:
Considerations for Counselors
Victoria E. White Kress, Karen P. Eriksen, Andrea Dixon Rayle,
and Stephanie J. W. Ford
Although counselors receive training in both diagnosis and cultural foundations of human behavior, little literature
or research integrates these 2 areas in order to facilitate culturally sensitive diagnostic practices. The authors
attempt to rectify that lack by providing a review of the literature on the controversies associated with traditional
diagnosis of cultural groups that differ from the dominant culture. Practical guidelines for culturally sensitive diagnosis
are provided.
According to the American Counseling Association (ACA;
1995), counselor training should contribute to knowledge
of different cultural groups, skills in counseling people from
diverse cultures, and awareness of one’s own stereotypes and
biases related to diverse populations (Standards A.2, A.5b,
and E.5b). The ACA ethical standards further state that counselors
do not discriminate on the basis of age, sex, race, or
sexual orientation and that they attempt to increase their
personal awareness, sensitivity, and skills with regard to
counseling diverse client populations (Standards A.2 and
E.5b). To this end, counselor trainees receive training in the
cultural foundations of human behavior and how to best
counsel people from diverse populations (Council for Accreditation
of Counseling and Related Educational Programs
[CACREP], 2001).
Community, family, and mental health counselors, and
some school counselors, also receive training on the use of
the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, text revision (DSM-IV-TR; American Psychiatric
Association [APA], 2000; CACREP 2001 Standards for
Community Counselors Section C.5.; CACREP 2001 Standards
for Mental Health Counselors Section C.4.). Despite
the requirement that counselors receive training in the DSM
and in cultural issues related to various aspects of counseling,
little literature or research addresses the interface of
these two important topics; this lack may lead some to the
erroneous assumption that cultural issues do not intersect
with counselors’ use of the DSM (Castillo, 1997; Lonner &
Ibrahim, 2002). (For the purposes of this article, we often
refer to the various editions of the DSM as simply the DSM.)
However, just as counselors are to display cultural competence
when counseling clients (Sue, Ivey, & Pedersen, 1996), it should
also be assumed that they must be culturally competent when
diagnosing these same clients.
Despite the paucity of literature melding culture and the
DSM, some researchers have documented the importance of
considering cultural issues in psychological assessment and
diagnosis (Cofresi & Gorman, 2004; Dana, Aguilar-Kitibutr,
Diaz-Vivar, & Vetter, 2002), and several authors have proposed
strategies for engaging in culturally sensitive diagnostic
practices (DSM-IV-TR; APA, 2000; Castillo, 1997; Eriksen
& Kress, 2004; Lonner & Ibrahim, 2002; Mezzich, 1999). For
example, the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV; APA, 1994) provides
counselors with an outline evaluating clients’ cultural contexts.
This cultural formulation helps counselors review (a)
clients’ cultural backgrounds, (b) possible cultural explanations
of clients’ issues, (c) possible cultural factors related to
clients’ psychosocial environment and functioning, (d)
cultural components affecting the client–counselor relationship,
and (e) an overall cultural assessment for proper
diagnosis and treatment (Lonner & Ibrahim, 2002; Tanaka-
Matsumi, Higginbotham, & Chang, 2002). Mezzich (1999)
has further stated that cultural competence with regard to
diagnosing entails understanding the cultural framework
of the client’s identity, cultural explanations of problems,
cultural attitudes and perceptions of help-seeking behavior,
cultural meanings of adaptive functioning, cultural
Victoria E. White Kress, Department of Counseling, Youngstown State University; Karen P. Eriksen, Old Dominion University;
Andrea Dixon Rayle, Division of Psychology in Education, Arizona State University; Stephanie J. W. Ford, Department of
Psychology, Baldwin-Wallace College. Karen P. Eriksen is now in the Department of Counseling Psychology at Argosy University,
Orange County. Correspondence concerning this article should be addressed to Victoria E. White Kress, Beeghley Hall,
Department of Counseling, Youngstown State University, Youngstown, OH 44555 (e-mail: vewhite@ysu.edu).
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 97

98
elements in the therapeutic relationship, and how to provide
a thorough cultural assessment.
In the professional literature, various possibilities for
culturally sensitive appraisal, assessment, and diagnosis have
been addressed (e.g., Lonner & Ibrahim, 2002). In this article,
we seek to summarize and expand the literature available
to counselors by providing counselors with a basic understanding
of the criticisms that have been leveled at the
DSM system of diagnosis by those sensitive to its impact on
nondominant cultural groups. This article also provides
guidelines for counselors who use the DSM with people from
various cultural backgrounds and who often use Western
diagnostic assumptions when diagnosing these clients
(Aubrey, 1991). Concrete suggestions for culturally sensitive
practice are provided.
Cultural Issues and the DSM:
Controversies and Criticisms
The DSM provides the primary diagnostic system for communicating
among professionals, obtaining reimbursements,
organizing and creating a conceptualization of client behaviors,
and determining what services clients need. Almost
all counseling settings in which community and mental
health counselors work require a DSM diagnosis for reimbursement
of services (e.g., hospitals, community mental
health centers, residential treatment settings, and private
practices). The DSM is a necessity for professional practice,
is the clearest and most thorough diagnostic system we currently
have, and, despite criticisms about its lack of cultural
sensitivity, is indeed an enduring system that is not about to
be replaced (Hinkle, 1999; Hohenshil, 1993).
The DSM system, however, is only one way of making
meaning of clients’ problems and concerns, and it has its
limitations. In particular, many criticisms have been directed
at the DSM with regard to cultural issues. Research and
literature on cross-cultural assessment, diagnosis, and treatment
continue to expose the inaccuracy of the DSM system
with underrepresented and marginalized groups. Such literature
points to the tendency of clinicians to overdiagnose,
underdiagnose, and misdiagnose clients from these groups
(Lonner & Ibrahim, 2002).
What Is Abnormal Behavior and Who Defines
Abnormal?
Throughout human history, people who have not conformed
to the then current societal conventions have been hospitalized,
expelled from their communities and religious organizations
(e.g., witches), and otherwise ostracized from society
and its privileges. For example, many Christian-European
settlers in the United States sought to convert the Native
American population whose worldview and practices were
perceived as barbaric. An assumption that a Christian-
Kress, Eriksen, Rayle, & Ford
European worldview and way of life was superior guided the
slaughter of much of the Native American population
(Wallace, 1995). Later, drapetomania, or the desire of
slaves to escape captivity, was perceived by the dominant
White culture to be pathological and maladaptive,
clearly an erroneous and irrational belief (Woolfolk, 2001).
Still today, many groups in the United States are marginalized
or discriminated against based on their cultural beliefs, race/
ethnicity, religion/spirituality, sexual orientation, and so on
(Arredondo, 2002).
Secondary to these historical and current blatant examples
of the marginalization of certain groups, many people
question who and what defines abnormal versus normal behavior.
As its name implies, the DSM is a model that is used
to determine the existence of mental disorders. At the root of
the word disorder are judgments about how abnormal behavior
is defined, definitions that cannot be separated from
an understanding of what constitutes normal behavior. Yet
who decides what is abnormal and thus defines mental disorders
as characterized in the DSM-IV (APA, 1994)? Marecek
(1993) noted that all judgments of abnormal behavior are
rooted in a conception of what an ideal life should be, along
with judgments about proper and improper forms of behavior.
Thus, decisions and judgments regarding the normalcy
of various behaviors, as published in the DSM, are being
made by medical and psychiatric professionals (Szasz, 1974).
However, these professionals are measuring all persons according
to some identified normal standard of behavior regardless
of the impact of culturally diverse backgrounds or
contexts (Pedersen, 2000). It is interesting that people of
color have been largely excluded from the development of
the DSM, which may mean that, unintentionally, little attention
has been paid to the role of ethnicity and culture in the
development of the diagnostic system (Velásquez, Johnson,
& Brown-Cheatham, 1993).
The problems with professionals failing to consider, when
diagnosing, the larger cultural and contextual issues become
clearer with greater consciousness of macrolevel social
explanations of problems of living. Such social problems
as racism, discrimination, patriarchy, homophobia, and
poverty currently affect all human experience, yet these can
become lost in the DSM’s focus on disorders being rooted in
the individual. The clear absence in the DSM of culturespecific
syndromes or culture-bound syndromes related to
macrolevel issues—such as acculturation adjustments, migration
and immigration trauma, ethnic-racial identity confusion,
or PTSD due to socially sanctioned racism or violence
(Velásquez et al., 1993)—can reduce such experiences
to invisibility if one adheres only to the DSM system of
assessment. Without consciousness, counselors may facilitate
clients’ conceptualizing their problems solely from an
individual disorder perspective rather than a more
macrocultural perspective that would take into account cultural
diversity and the issues surrounding marginalized
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83

The DSM-IV-TR and Culture
groups. There are authors (Kutchins & Kirk, 1997; Szasz,
1974) who further note the potential for an abuse of power
secondary to an imposition of values about normalcy, and
some state that mental health professionals run the risk of
becoming agents of social control by “doing” diagnoses to
clients (Seligman, Walker, & Rosenhan, 2001; Tomm, 1989).
Can Science Ever Be Objective?
Many have questioned the claims by DSM developers that
the manual is based on science. Kutchins and Kirk (1997),
for instance, question the seemingly scientific process of
developing and assigning various mental disorders, claiming
that the process has been laden with political agendas
about what should or should not be included in the DSM.
This may be due in part to cultural encapsulation, or ethnocentric
views held by those individuals who have historically
defined the various DSM disorders.
Furthermore, research on cultural issues has been historically
and politically complicated (Guthrie, 1976). For example,
attempts to classify people in the early 1900s based
on racial differences, mental abilities, and character traits
led to conclusions of racial superiority and inferiority. These
scientific conclusions were considered superior to previous
conclusions that were based on religion or tradition (Guthrie,
1976). However, such conclusions point out the fact that the
questions a researcher asks in the name of science can never
be unbiased; the simple asking of a question or statement of
a hypothesis can unite bias and science. Instead of researchers
simply asking, “What are the facts?” they might also ask
themselves “What are the assumptions?” Instead of researchers
asking, “What are the answers?” researchers may benefit
from asking, “What are the questions being asked and why
are they being asked?” (White, 2001).
Cross-Cultural Viewpoints
Cross-cultural studies (i.e., anthropological and sociological
studies of those from different countries rather than psychological
studies that seek to determine the differences
between cultural groups in the United States) have led the
way in spurring the move away from disease-centered psychiatry.
Such studies have made it clear that culture influences
the duration, the course, and the outcome of mental
illness. Castillo (1997), for instance, reported findings that
indicate that culture affects clients’ perceptions of reality,
and thus counselors’ perceptions of clients, in a number of
ways including what kinds of problems clients report, what
meaning of the symptoms is projected by clients’ communities,
how symptoms are perceived by clients, what assumptions
the community relays to the person with the problem,
how clients interpret and judge their problems, and how
people in that culture behave in order to express that they
are ill. There is no culture that does not assign its own meanings
to its members’ personalities, intelligence, behaviors,
and abilities, as well as problems and illnesses (Lonner &
Ibrahim, 2002). All of the aforementioned issues have an impact
on the relationship between the client and the problem,
the counselor and the problem, the client and the counselor,
and thus the counselor’s assessment and diagnosis of the client.
Because the DSM-IV-TR (APA, 2000) offers insufficient
aid to mental health professionals aiming to provide culturally
sensitive and appropriate assessment, diagnosis, and
interventions to diverse clients (Dana, 1998), many people
of color have challenged the DSM system, in particular, challenging
traditional notions of mental illness. For instance,
Velásquez et al. (1993) pointed out that no discussion exists
in the DSM of how specific diagnoses present or manifest
themselves in people of color. The DSM could include data
about key features, unique symptoms, or prevalence of specific
diagnoses in people of color. Velásquez et al. also indicated
that empirical evidence reveals that using the DSM is
not valid or reliable with people of color. There is evidence
that diagnosis of nondominant groups is highly susceptible
to human error, errors that are particularly compounded in
the diagnosis of linguistically diverse clients.
Practice Considerations for Counselors
Despite numerous efforts to remedy these problems, misdiagnosis
concerns remain when working with clients from
ethnically and culturally diverse backgrounds and
worldviews (Tanaka-Matsumi & Draguns, 1997). The following
case study provides an example of the complexities
associated with culturally sensitive diagnosis.
Michael is a 25-year-old African American man residing in the
eastern United States. He reports being reared in a loving family
environment. He smiles as he shares memories of spending time
with his immediate and extended family and recollects fond moments
of the fun they had together. Currently, his occupation
keeps him busy, and he is able to spend occasional weekends and
holidays with his family. He reports being fulfilled at work, and
he occasionally dates. Recently, he has been spending a lot of
time with his male friends discussing life’s issues and the challenges
of daily living. Currently, Michael is going up for a promotion
at his company and is concerned with his ability to “climb
the corporate ladder.” He has decided to seek counseling to discuss
his sleeplessness and concern regarding the promotion.
While in counseling, he reports feeling anxious and is concerned
that people are always watching and observing him. He states he
is always cautious when he sees a police officer because he is not
sure if he will be pulled over. The counselor has Michael complete
a Minnesota Multiphasic Personality Inventory-2 (MMPI-
2; Butcher et al., 2001). His test results indicate an elevated score
on the Paranoia scale.
Overall, counselors approaching this case and others might
engage in more culturally sensitive diagnostic practices if
they increase their knowledge of the strengths and weak-
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 99

100
nesses of the DSM model, conduct comprehensive and culturally
sensitive assessments on all clients, focus more energy
on Axis-IV diagnosis, increase their personal awareness
of culture and bias, engage in collaborative diagnosis and
treatment, relate to clients in culturally sensitive ways, and
carefully consider whether diagnosing will be helpful
(Eriksen & Kress, 2004). A more thorough discussion of each
of these notions and how they relate to Michael follows.
Knowledge of the Strengths and Weaknesses of the
DSM Model
Some authors and practitioners suggest that counselors
should be taught to be critical of the DSM, to recognize its
imperfections, and to identify critical incidents in which
DSM diagnoses can be unethical and oppressive to people
of color (Velásquez et al., 1993; White, 2001). For example,
although the DSM-IV (APA, 1994) includes a glossary of 25
culture-bound syndromes for use with culturally and racially
diverse clients, this is by no means an exhaustive list and is
limited when used for the assessment and diagnosis of people
of color. Guarnaccia and Rogler (1999) noted that due to
possible differences in meaning between cultures, mental
health professionals should not try to fit the DSM-IV culturebound
syndromes into the main text’s classification systems
without completely investigating the individual’s unique
experiences. Although some of the culture-bound syndromes
seem similar to the disorders in the main text, practitioners
need to remain cognizant of the many differences that exist
within and between cultures and individuals (Guarnaccia &
Rogler, 1999; Thakker, Ward, & Strongman, 1999). Relatedly,
counselors should examine their personal and societal
beliefs about normal and abnormal behavior in various
cultures (Velásquez et al., 1993; White, 2001).
In the case of Michael, it is important to explore how he
personally defines his sleeplessness, his anxiety, and his
concerns about others always watching and observing him.
Asking Michael how his personal and cultural history affects
these feelings and experiences will aid in helping him
to find the root of these concerns. Despite his symptomatology
and his MMPI-2 score, counselors should not assume
that Michael’s sleeplessness, anxiety, and feelings about
being watched are due to any specific paranoid personality
diagnosis, because they very likely could be due to actual
experiences in his life related to institutionalized racism
(Sue & Sue, 2003). Phelps, Taylor, and Gerald (2001), for
instance, documented the healthy cultural paranoia of African
Americans, which serves as an adaptive coping strategy.
Thorough and Sensitive Cultural Assessment
Castillo (1997) and Dana (1998) stated that comprehensive
cultural assessment is critical to work with any client, because
culture directly affects clinical presentation and counselor
perceptions. Other mental health professionals have
Kress, Eriksen, Rayle, & Ford
petitioned for incorporating “culturalogical” interviewing
with psychological and medical assessments for diagnosis
and treatment (Marsella & Kaplan, 2002). Culturalogical
interviews provide additional information on the client’s life
context and perceptual meanings and can ultimately facilitate
comprehensive care (Marsella & Kaplan, 2002). Castillo
(1997) stated, for instance, that emotions connect with culture
at three stages—the client’s initial appraisal of the meaning of
an event, his or her emotional feeling, and his or her behavioral
response—and that these will all be based on culturally
determined norms and roles. It is thus important for mental
health professionals to remember that 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.
In the case of Michael, the meanings he associates with
his emotions and behaviors may be closely related to his
cultural schema. Through a culturalogical interview, his
counselor may find that the meanings he has for his anxiety
and sleeplessness may be culturally natural responses based
on similar situations in his life or in the lives of others to
whom he is close. His paranoia may very likely exist due to
instances in which he has found himself racially profiled
because of his skin color and appearance or instances in
which, as a person of color, he was seen as inadequate. It is
the counselor’s responsibility to assess and explore Michael’s
meanings and cultural schema before attempting to diagnose
him with traditional Western diagnostic frameworks,
such as those within the DSM-IV (APA, 1994). In addition to a
culturalogical interview, Michael’s counselor may want to
use assessments to measure his level of acculturation in an
attempt to better understand his worldview and cultural identity.
Cross’s (1991, 1995) model of psychological nigrescence
addresses the process of being Black and may be helpful in
better understanding Michael. It is essential for the counselor
to gain an understanding of his beliefs, values, and
lifestyle. Instruments such as the African Self-Consciousness
Scale (Baldwin & Bell, 1985), the Black Racial Identity
Scale (Helms & Parham, 1990), the African American
Acculturation Scale (Landrine & Klonoff, 1994), and the
Multigroup Ethnic Identity Measure (Phinney, 1992) are
useful processing tools to assist with exploration and increase
the counselor’s awareness of Michael’s worldview.
Assess the client’s worldview. Assessing a client’s
worldview, or how the client views the world from social,
ethical, moral, and philosophical perspectives, is necessary
to comprehensive, culturally sensitive assessment (Lonner
& Ibrahim, 2002). Lonner and Ibrahim suggested that counselors
must include their clients’ cultural worldviews and
schemas in the counseling process for a diagnosis to be meaningful
to clients. This should include a “multimethod assessment
program” that incorporates the counselors’ own
understanding of clients’ cultural beliefs, values, and
worldviews (p. 357). A client’s worldview includes his or her
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83

The DSM-IV-TR and Culture
values, beliefs, and assumptions about the world; these will
differ based on a client’s cultural, social, religious/spiritual,
and/or ethnic/racial background. Recent research has illustrated
that a client’s worldview is the most vital variable to
assess in cross-cultural counseling (Grieger & Ponterotto,
1995; Ibrahim, Roysircar-Sodowsky, & Ohnishi, 2001). A
widely used instrument to assess worldview is the Scale to
Assess Worldview (SAWV; Ibrahim & Kahn, 1984, 1987;
Ibrahim & Owen, 1994).
Assess the client’s cultural identity. Understanding a client
also requires understanding the client’s sense of him- or
herself culturally, or his or her stage of cultural identity awareness.
The professional should never assume that all culturally
different clients maintain the same relationship with
the values and norms of their culture (Red Horse, 1983).
Although two similar clients may have similar worldviews,
their cultural identities may differ dramatically.
Assessing for a particular client’s acculturation level may
be critical to therapeutic effectiveness. In order to conduct
an accurate acculturation or cultural identity assessment,
mental health professionals should obtain information from
clients about their language, religious beliefs, educational
status, employment, societal norms, social status, media
usage, social relations, and gender roles (Atkinson, Morten,
& Sue, 1998; Berry, 1990; Castillo, 1997; Mezzich, 1999).
Racial and cultural identity models have assisted with developing
an understanding of the role of culture in an
individual’s life (Atkinson et al., 1998). Identity models
provide a conceptual framework for understanding the attitudes
and behaviors of diverse clients. Racial and cultural
identity models have allowed mental health professionals
to have an awareness of distinct cultural variables and prevent
professionals from having a monolithic view of clients
(Atkinson et al., 1998).
When working with Michael, his counselor may want to
assess what stage he is in according to the Cross (1971, 1991,
1995) model of psychological nigrescence, or the process of
becoming Black. The Cross model delineates a five-stage process
during which Black Americans move from a White frame
of reference to a Black frame of reference and recognize the
racism and discrimination that they may be victim to daily.
The possible stages in the Cross (1995) model include the
preencounter, encounter, immersion, emersion, internalization,
and internalization-commitment stages.
Assess sources of cultural information relevant to the client.
Culturally sensitive professionals study the cultures of
the clients that they are likely to see in their practices. Information
about clients’ cultures can be obtained through professional
development activities, consultation, reading relevant
books, visiting churches and other culturally defined
places, and identifying key members of a cultural community
to serve as consultants (Castillo, 1997; Mezzich, 1999).
When assessing cultural information with Michael, his
counselor may want to ask about the neighborhood where
Michael grew up versus where he lives now; about his family
beliefs and traditions versus the history and development
of the company he works for; and about his past and
current social support systems, spirituality, and activities.
Information about each of these areas of his life will offer his
counselor an inside look into his past cultural history and
how it shaped his worldview, as well as offer information
about his personal culture now and how it might clash with
the culture of his work environment.
Assess the cultural meaning of a client’s problem and
symptoms. If a mental health professional only treats a client’s
symptoms and not the cause of the symptoms, the course
and outcome of the case is likely to be poor. The mental
health professional, therefore, must understand the client’s
beliefs about the development of the problem. What does
the client believe to be the cause of the symptoms/problem,
the problem’s effects on self and others, and the likely treatment
of symptoms? Views of mental illness vary in different
cultures, as do beliefs about the professional’s role in treatment.
In some cultures, for instance, problems are perceived
to be caused by spirit possession, bad luck, or excess semen
(Castillo, 1997; Mezzich, 1999). In other cultures, a problem
as defined by the mainstream culture may not be seen
by the client as a problem at all.
Assessing Michael’s personal definitions and meanings of
the concerns that brought him into counseling is integral to
assessment, diagnosis, and treatment. For Michael, it may be
that his sleeplessness and anxiety are considered very normal
under the circumstances. The paranoia he is experiencing
about others always watching him may be a very valid reaction
to the years of oppression and racism he has experienced
in the U.S. because he is an African American male in a Whitedominated
society. Before accurate diagnosis can take place,
his counselor needs to understand in a cultural context how
Michael views the concerns he is experiencing. A counselor
can do this by asking Michael to talk about other times in his
life when he had experienced similar feelings about his internal
responses to these feelings, and by helping him to make
connections (if accurate) between his cultural beliefs and
actual psychological disturbance.
Assess the impact and effects of family, work, and community
on the complaint. Mental health professionals should
assess clients and their problems within the total sociocultural
context. Thus, clients’ social environment, values, and
beliefs are very important in understanding their problems
and in structuring the course and outcome of treatment
(Castillo, 1997; Mezzich, 1999). Assessing Michael’s family,
work, and social support in depth will lead to understanding
Michael in his full sociocultural context. Also, this can lead
to further unveiling of Michael’s personal and cultural beliefs
and values. The counselor’s awareness of this vital information
will be beneficial in providing effective treatment.
Assess stigmas associated with the problem. Clients, even
those with severe mental illness, are sensitive to cultural
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 101

102
meanings of their problems and others’ responses to their problems.
It is important for the professional to learn about clients’
experiences with stigma, prejudice, and discrimination, and to
understand clients’ reactions to these experiences (Castillo, 1997).
It will be important, for instance, to praise Michael for coming to
counseling, despite the possible stigmas that remain for him
about seeking help. His counselor would want to better understand
how Michael views counseling and the possible stigmas
and prejudices that may result from diagnosis of his concerns.
The counselor and Michael should explore his life experiences
and personal reactions to stigmas, prejudice, and discrimination.
Increasing Emphasis on Axis IV
Emphasizing Axis IV during diagnosis may ensure a more
culturally sensitive diagnosis (Vontress, Johnson, & Epp,
1999; White, 2001). For instance, Vontress and his colleagues
suggested that economic problems in disadvantaged communities
often produce a variety of psychological and social
problems. They propose attending closely to Axis IV
information because psychosocial and environmental problems
often affect the diagnosis, treatment, and prognosis of
Axis I and II disorders. The salience of Axis IV information is
essential when looking at culturally diverse groups. For example,
in the case of Michael it is important for counselors
to be aware of environmental and psychological problems
he may be experiencing. Michael’s current psychosocial
stressors could be significantly affecting his ostensible Axis
I and Axis II diagnoses.
Counselor Personal Awareness
When they have presented multicultural training and education
and have disseminated multicultural guidelines, influential
leaders in multicultural counseling have touted
the importance of increasing practitioners’ cultural awareness
(Sue, Arredondo, & McDavis, 1992). ACA (1997)
adopted its multicultural competencies as a foundation for
ethically and competently guiding counselors in their mental
health work with diverse groups. Furthermore, recent
ideas, such as cultural sensitivity and cultural empathy, have
permeated counseling research and training, making clear
the value that is being placed on increasing counselors’ personal
knowledge, skills, and awareness in the area of crosscultural
counseling (Chung & Bemak, 2002).
Clearly, then, counseling leaders advocate increasing
personal awareness about cultural issues for all practitioners.
The onus is now on individual providers to become
more aware of their own biases, values, and stereotypes (Sue
& Sue, 2003). If a professional is not aware of his or her own
cultural schemas, these may be projected onto the client and
result in improper diagnosis and treatment. Mental health
professionals should exhibit empathy and should attempt
to see the situation from the client’s perspective as much as
possible (Castillo, 1997).
Kress, Eriksen, Rayle, & Ford
Collaborative Diagnosis and Treatment
The diagnosis of clients is multifaceted, and cultural and
subcultural variables often present challenges to the counselor
when diagnosing and counseling clients (Mezzich,
1999). The act of diagnosing clients requires mental health
professionals to conceptualize clients’ situations. This requires
counselors to be aware of cultural norms and acculturation
issues and how these may be congruent or incongruent with
the diagnostic criteria of the DSM-IV-TR (APA, 2000). It essential
to ensure that clients are not overpathologized. If mental
health professionals and clients collaborate in developing
diagnoses, counseling goals, and methods for reaching those
goals, some of these problems can be rectified. When the
problem and goals are understood by and are significant to
the client, he or she will have more incentive to have a
commitment to counseling (Castillo, 1997; Mezzich, 1999).
Therefore, culturally sensitive practices include supporting
the client’s own understanding, construction, and reality of
the problem, as long as his or her understanding includes
the possibility of eventual problem resolution (Castillo,
1997). An increase in the client’s sense of understanding of
the problem may facilitate a client’s sense of control in managing
the problem. Collaboration may extend beyond the
client–counselor relationship to consultations with individuals
in the client’s life whom he or she believes to be
knowledgeable and to have expertise (e.g., family members,
folk healers). In Michael’s case, it may be prudent for the
counselor to ask to consult with friends and/or family members
when conceptualizing Michael’s concerns. In addition,
it may be worthwhile for a non–African American counselor
to consult with a counselor who is competent regarding the
African American experience in the U.S. today.
Use of Culturally Sensitive Interpersonal Skills
Numerous authors (Castillo, 1997; Ivey & Ivey, 2003; Sue
& Sue, 2003) suggest that adjusting the interviewing style
(eye contact, personal space, rate of speech) to the cultural
norms and preferences of the client can be helpful in facilitating
a culturally sensitive interview and in understanding
clients’ problems. Counselors and counselors-in-training
should be given or should seek out opportunities to
actually apply and use such interviewing skills with people
of color (Velásquez et al., 1993), because universal interview
techniques may not be beneficial for all clients. As
counselors begin to work in this ever-changing society, it
will be appropriate to modify interviews in order to solicit
detailed information in a nonthreatening manner as well as
assess the data from a culturally relevant perspective. In
the case of Michael, the counselor would benefit from approaching
him in an interpersonal style that is consistent
with Michael’s own style and/or the interpersonal style consistent
with other people in his life.
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83

The DSM-IV-TR and Culture
Before diagnosing any client, counselors also might ask
themselves the following:
1. Have I been able to separate what is important to me
and what is important to this particular client?
2. What do I know about this client’s cultural heritage?
3. What do I not know about this client’s cultural heritage?
4. What is this client’s relationship with his or her culture
from his or her perspective?
5. To what degree is the client acculturated to the dominant
culture?
6. What are my stereotypes, beliefs, and biases about
this culture, and how might these influence my understandings?
7. What culturally appropriate strategies/techniques
should be incorporated in the assessment process?
8. What is my philosophy of how pathology is
operationalized in individuals from this cultural group?
9. Have I appropriately consulted with other mental
health professionals, members from this particular
culture, and/or members of this client’s family or extended
family?
10. Has this client aided in the construction of my understanding
of this problem?
Conclusion
In this article, we urge counselors toward culturally sensitive
diagnostic practices because these are ethically required and
necessary to effective mental health treatment. For instance, we
encourage counselors to conduct a thorough assessment of their
clients’ cultural realities and to develop an appreciation of the
layered issues associated with use of the DSM. Also, a complex
understanding of the nature of the DSM is important when working
with any client, but it is particularly important when working
with clients from diverse populations. As an example, counselors
need to carefully consider all aspects of clients’ culture in conjunction
with the clients’ past and present life circumstances to
avoid misdiagnosis or the use of unnecessary diagnoses. It is
hoped that ascribing accurate and least-restrictive diagnoses will
help counselors to avoid potentially destructive, enduring labels
and overly restrictive and invasive treatment practices.
References
American Counseling Association. (1995). ACA code of ethics and
standards of practice. Alexandria, VA: Author.
American Counseling Association. (1997). Multicultural competencies.
Alexandria, VA: Author.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text revision). Washington,
DC: Author.
Arredondo, P. (2002). Counseling individuals from marginalized
and underserved groups. In P. B. Pedersen, J. G. Draguns, W. L.
Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th
ed., pp. 233–249). Thousand Oaks, CA: Sage.
Atkinson, D. R., Morten, G., & Sue, D. W. (1998). Counseling
American minorities (5th ed.). Boston: McGraw Hill.
Aubrey, R. (1991). International students on Campus: A challenge
for counselors, medical providers, and clinicians. Smith College
Studies in Social Work, 62(1), 20–33.
Baldwin, J. A., & Bell, Y. (1985). The African Self-Conscious Scale:
An Africentric personality questionnaire. Western Journal of Black
Studies, 9, 61–68.
Berry, J. W. (1990). Psychology of acculturation. Nebraska Symposium
on Motivation, 37, 201–234.
Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., Tellegen, A.,
Dalhstrom, W. G., & Kaemmer, B. (2001). Minnesota Multiphasic
Personality Inventory-2 (MMPI-2): Manual for administration,
scoring, and interpretation (Rev. ed.). Minneapolis: University
of Minnesota Press.
Castillo, R. J. (1997). Culture and mental illness: A client centered
approach. Pacific Grove, CA: Brooks Cole.
Chung, R. C., & Bemak, F. (2002). The relationship of culture and
empathy in cross-cultural counseling. Journal of Counseling &
Development, 80, 154–159.
Cofresi, N. I., & Gorman, A. A. (2004). Testing and assessment
issues with Spanish-English bilingual Latinos. Journal of Counseling
& Development, 82, 99–106.
Council for Accreditation of Counseling and Related Educational
Programs. (2001). Accreditation manual and application. Alexandria,
VA: Author.
Cross, W. E. (1971). The Negro-to-Black conversion experience: Towards
a psychology of Black liberation. Black World, 20, 13–27.
Cross, W. E. (1991). Shades of black: Diversity in African American
identity. Philadelphia: Temple University Press.
Cross, W. E. (1995). The psychology of nigrescence: Revising the
Cross model. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, &
C. M. Alexander (Eds.), Handbook of multicultural counseling
(pp. 357–374). Thousand Oaks, CA: Sage.
Dana, R. H. (1998). Understanding cultural identity in intervention
and assessment. Thousand Oaks, CA: Sage.
Dana, R. H., Aguilar-Kitibutr, A., Diaz-Vivar, N., & Vetter, H.
(2002). A teaching method for multicultural assessment: Psychological
report contents and cultural competence. Journal of
Personality Assessment, 79, 207–215.
Eriksen, K., & Kress, V. E. (2004). Beyond the DSM story: Ethical
quandaries, challenges, and best practices. Thousand Oaks, CA:
Sage.
Grieger, I., & Ponterotto, J. G. (1995). A framework for assessment
in multicultural counseling. In J. G. Ponterotto, J. M. Casas, L. A.
Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural
counseling (pp. 357–374). Thousand Oaks, CA: Sage.
Guarnaccia, P. J., & Rogler, L. H. (1999). Research on culturebound
syndromes: New directions. The American Journal of
Psychiatry, 156, 1322–1327.
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83 103

104
Guthrie, R. V. (1976). Even the rat was white: A historical view of
psychology. San Francisco: Harper & Row.
Helms, J. E., & Parham, T. A. (1990). Black Racial Identity Scale. In
J. E. Helms (Ed.), Black and White racial identity: Theory, research,
and practice (pp. 245–247). Westport, CT: Greenwood.
Hinkle, J. S. (1999). A voice from the trenches: A reaction to Ivey
and Ivey (1998). Journal of Counseling & Development, 77,
474–483.
Hohenshil, T. H. (1993). Teaching the DSM-III-R in counselor education.
Counselor Education and Supervision, 32, 267–275.
Ibrahim, F. A., & Kahn, H. (1984). Scale to Assess World View
(SAWV). Unpublished instrument, Storrs, CT.
Ibrahim, F. A., & Kahn, H. (1987). Assessment of world views.
Psychological Reports, 60, 163–176.
Ibrahim, F. A., & Owen, S. V. (1994). Factor analytic structure of the
Scale to Assess World View. Current Psychology: Development,
Learning, Personality, Social, 13, 201–209.
Ibrahim, F. A., Roysircar-Sodowsky, G., & Ohnishi, H. (2001).
Worldview: Recent developments and needed directions. In J. G.
Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.),
Handbook of multicultural counseling (2nd ed., pp. 425–456).
Thousand Oaks: Sage.
Ivey, A. E., & Ivey, M. B. (2003). Intentional interviewing and
counseling: Facilitating client development in a multicultural
society. Pacific Grove, CA: Brooks/Cole.
Kutchins, H., & Kirk, S. A. (1997). Making us crazy: DSM: The
psychiatric bible and the creating of mental disorders. New
York: The Free Press.
Landrine, H., & Klonoff, E. (1994). The African American Acculturation
Scale: Development, reliability, and validity. Journal of
Black Psychology, 20, 104–127.
Lonner, W. J., & Ibrahim, A. A. (2002). Appraisal and assessment in
cross-cultural counseling. In P. B. Pedersen, J. G. Draguns, W. L.
Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th
ed., pp. 355–379). Thousand Oaks: Sage.
Marecek, J. (1993). Disappearance, silences, and anxious rhetoric:
Gender in abnormal psychology textbooks. Journal of Theoretical
and Philosophical Psychology, 13, 115–123.
Marsella, A. J., & Kaplan, A. (2002). Cultural considerations for
understanding, assessing, and treating depressive experience
and disorder. In M. A. Reinecke & M. R. Davison (Eds.),
Comparative treatments of depression (pp. 47–78). New York:
Springer.
Mezzich, J. E. (1999). Ethics and comprehensive diagnosis. Psychopathology,
32, 135–140.
Pedersen, P. B. (2000). Handbook for developing multicultural
awareness (3rd ed.). Alexandria, VA: American Counseling
Association.
Phelps, R. E., Taylor, J. D., & Gerald, P. A. (2001). Cultural mistrust,
ethnic identity, racial identity, and self-esteem among ethnically
diverse Black university students. Journal of Counseling & Development,
79, 209–216.
Kress, Eriksen, Rayle, & Ford
Phinney, J. S. (1992). The Multigroup Ethnic Identity Measure: A
new scale for use with diverse groups. Journal of Adolescent
Research, 7, 156–176.
Red Horse, J. G. (1983). Indian family values and experiences. In
G. J. Powell, J. Yamamoto, A. Romero, & A. Morales (Eds.),
The psychosocial development of minority group children (pp.
258–272). New York: Brunner/Mazel.
Seligman, M. E. P., Walker, E. F., & Rosenhan, D. L. (2001). Abnormal
psychology. New York: Norton.
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural
competencies/standards: A call to the professional. Journal
of Counseling & Development, 70, 477–486.
Sue, D. W., Ivey, A. E., & Pedersen, P. B. (Eds.). (1996). A theory
of multicultural counseling and therapy. Pacific Grove, CA:
Brooks/Cole.
Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse:
Theory and practice (4th ed.). New York: Wiley.
Szasz, T. S. (1974). The myth of mental illness. New York: Harper
& Row.
Tanaka-Matsumi, J., & Draguns, J. (1997). Culture and psychopathology.
In J. W. Berry, M. H. Segall, & C. Kagitçibasi (Eds.),
Handbook of cross-cultural psychology: Volume 3. Social behavior
and applications (2nd ed., pp. 449–491). Boston: Allyn
& Bacon.
Tanaka-Matsumi, J., Higginbotham, H. N., & Chang, R. (2002).
Cognitive-behavioral approaches to counseling across cultures.
In P. B. Pedersen, J. G. Draguns, W. L. Lonner, & J. E. Trimble
(Eds.), Counseling across cultures (5th ed., pp. 337–354). Thousand
Oaks, CA: Sage.
Thakker, J., Ward, T., & Strongman, K. T. (1999). Mental disorder
and cross-cultural psychology: A constructivist perspective. Clinical
Psychology Review, 19, 843–874.
Tomm, K. (1989). Externalizing the problem and increasing personal
agency. Journal of Strategic and Systemic Therapies, 8, 54–59.
Velásquez, R. J., Johnson, R., & Brown-Cheatham, M. (1993).
Teaching counselors to use the DSM-III-R with ethnic minority
clients: A paradigm. Counselor Education and Supervision, 32,
323–331.
Vontress, C. E., Johnson, J. A., & Epp, L. R. (1999). Cross-cultural
counseling: A casebook. Alexandria, VA: American Counseling
Association.
Wallace, D. W. (1995). Education for extinction: American Indians
and the boarding school experience 1875–1928. Lawrence: University
Press of Kansas.
White, V. E. (2001). Renaming and rethinking the “diagnosis and treatment”
course. In G. A. McAuliffe & K. Eriksen’s (Eds.), Teaching
counselors and therapists: Constructivist and developmental course
designs (pp. 203–218). Westport, CT: Bergin & Garvey.
Woolfolk, R. L. (2001). “Objectivity” in diagnosis and treatment.
In B. D. Slife, R. N. Willimans, & S. H. Barlow (Eds.), Critical
issues in psychotherapy: Translating new ideas into practice
(pp. 287–298). London: Sage.
Journal of Counseling & Development ■ Winter 2005 ■ Volume 83