Assessing the filters through which we experience the world
There are aspects of our humanness that are so integral in defining who we are to ourselves and in relation to others, that they serve as permanent, albeit unconscious, filters through which we experience the world and judge others. Culture, race and ethnicity are filters of this nature, and their influence is pervasive. In the context of psychopathology, these aspects mold our conception of normal and abnormal. Thus, they figure into our definitions of diagnostic criteria and syndrome etiology. Based on this, they also represent factors in the prescription of treatment strategies and interventions.
Regarding clinical presentation, Tseng & Streltzer (1997) point out that how “the problem, symptom or illness is presented or communicated to the clinician is based on the patient’s (or the family’s) orientation to illness, the meaning of the symptom, motivation for help-seeking, and culturally expected or sanctioned problem-presenting style” (p. 13). Following this observation into the process of diagnosis, “A clinician, as a human being, as a cultural person, and as a professional person, will have different ways of perceiving and understanding the complaints that are presented by patients. Psychological sensitivity, cultural awareness, and professional experience, as well as medical competence, will all act together to influence the assessment of the problems a patient has presented” (p. 14). Thus, the diagnostic process and subsequent treatment is influenced by the cultural background of both the patient and the clinician.
With regard to depression, cultural and ethnic factors have considerable influence in aspects of clinical presentation. While the standard American manifestation of depression concentrates most often on the subjective report of affective symptoms, other cultures more commonly manifest symptoms of a somatic nature. This is attributed to the cultural stigmatization of emotional disorders and relative legitimization of physical distress. Furthermore, based on cultural and/or religious beliefs, some patients describe the symptoms in terms of possession, which, without an understanding of the patient’s cultural background, could be mistakenly diagnosed as delusional. Fundamental cultural differences exist, as well, in factors such as the subjective boundary between normal and pathological grief and bereavement and the level of impairment which constitutes clinical behavior (Tseng & Streltzer, 1997).
In terms of diagnosis, differentiation of normal from pathological behavior and disturbances of mood must take into account the patient’s cultural context. Behavior that can appear abnormal when assessed from one perceptual set may make perfect sense in relation to another conglomeration of values and beliefs. The specific manifestations of depressive symptoms (or conversely, the lack thereof) and their relative intensity, especially when occurring in relation to specific triggering life events or circumstances (i.e. death, illness, loss of job) can vary significantly between different cultures. As Lazarus & Folkman, (1989) concluded, “There appears to be some cultural variability, in the conditions under which it is appropriate to express one's feelings and in the patterns of outward expression such as crying and laughing (as cited in Amankwaa, 2003, p. 23). Furthermore, they went on to conclude that, “Not only are expression of emotion, management of emotion in certain situations, outward expression of feelings, and patterns of feelings affected by culture but they can be different according to ethnicity, social class, and role within cultures (p. 24). These varying expectations exist in a reciprocal relationship between the patient and the diagnostician. Therefore, a truly accurate, meaningful and therapeutically relevant diagnosis can only occur with consideration of these interacting influences.
Taking the consideration of culture into the treatment arena, therapists must assess variables, such as a patient’s support network, the cultural beliefs regarding psychological disorders and treatment, etc. which can serve either to reinforce or to hinder the progress of treatment (Tseng & Streltzer, 1997). Just as there are social determinants of the symptomology of a disorder, there are also similar factors which influence a patient’s response to treatment interventions. Effective treatment planning and progress assessment must consider these powerful aspects of a client’s context.
The interpretation of presenting clinical symptoms, the resulting diagnosis and the subsequent treatment regimen represent dynamic and interdependent facets of a patient’s mental health care plan. Each aspect requires the interaction of patient and therapist, each of whom brings to the situation a set of fundamental beliefs and perceptive filters for assessing their experiences that are heavily influenced by their cultural and ethnic backgrounds. In order for the process of diagnosis and therapy to be effective and ethical, these context issues must be incorporated into the whole clinical picture. Otherwise, the patient will be assessed against a potentially invalid measure and intervention could be at best, ineffective and at worst, harmful.
References
Amankwaa, L. C. (2003). Postpartum depression, culture and African-American women. Journal of cultural diversity, 10, 23-29.
Tseng, W. S. & Streltzer, J. (Eds.) (1997). Culture & psychopathology: A guide to clinical assessment. New York, NY: Brunner/Mazel Publishers.