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:– 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