The DSM-IV-TR and Culture

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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
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The DSM-IV-TR and Culture

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