Task 5. What’s the fuss?
Learning goals
What are potential sources of bias in the clinical encounter with individuals from different
cultures and what can you do against them?
Leong, F. T. L., & Kalibatseva, Z. (2016). Threats to cultural validity in clinical diagnosis and
assessment: Illustrated with the case of Asian Americans. In N. Zane, G. Bernal, & F.T.L.
Leong, Evidence-based psychological practice with ethnic minorities: Culturally informed
research and clinical strategies, 57-74.
Introduction
Clinical diagnosis and assessment are key aspects of psychotherapy. This chapter presents a
conceptual model for evaluating threats to cultural validity in clinical diagnosis and
assessment among racial and ethnic minorities and Asian Americans, in particular. Culturally
informed evidence-based practice requires accurate diagnosis and assessment of racial and
ethnic minority clients. However, there are challenges and threats to arriving at such
culturally sensitive and appropriate diagnosis and assessment of culturally diverse patient
populations.
Clinical diagnosis is of great importance because appropriate treatment may depend on a
correct diagnosis. Diagnosis of mental disorders has four major goals:
1. By giving someone a diagnosis, the mental health professional attempts to identify the
problems.
2. The professional tries to recognize the factors contributing to and maintaining the
identified problems.
3. When a diagnosis is present, the professional can choose and carry out the most
appropriate course of treatment.
4. The professional can change the treatment to meet the needs of the client if necessary.
A number of significant problems have been associated with the clinical diagnosis of
psychopathology and the value of the diagnostic process has remained controversial.
Concept of cultural validity
An essential problem in assessment and clinical diagnosis has been the neglect of the role of
cultural differences on psychopathology. The ethnic validity model of Tyler et al. refers to
the “recognition, acceptance, and respect for the presence of communalities and differences
in psychosocial development and experiences among people with different ethnic or cultural
heritages”. The issue of cultural validity in assessment and clinical diagnosis includes an
exploration of inaccuracies in evaluation and diagnosis due to differences in race, ethnicity,
nationality, or culture. The concept of cultural validity refers to the effectiveness of a
measure or the accuracy of a clinical diagnosis to address the existence and importance of
essential cultural factors. Such cultural factors may include values, beliefs, experiences,
communication patterns, and epistemologies inherent to the clients’ cultural backgrounds.
The lack of cultural validity in clinical diagnosis could result in two major sets of problems: 1)
clinically, the lack of cultural validity may result in an incorrect diagnosis and ineffective
treatment of culturally different populations, and 2) socially, such individuals may be
unnecessarily stigmatized and institutionalized as a result of diagnostic errors.
,The cultural uniformity assumption prevents clinicians from recognizing cultural differences
that may affect the assessment and diagnosis of culturally diverse clients. This is the
perspective that assumes that all people develop along uniform psychological dimensions.
Several major factors may contribute to the lack of cultural validity in clinical diagnosis.
The lack of cultural validity in clinical assessment and diagnosis can be conceptualized in
terms of multiple threats to validity. These threats to cultural validity in clinical assessment
are largely due to a failure to recognize or a tendency to minimize cultural factors in clinical
assessment and diagnosis. This review suggests that several factors may serve as the sources
of threats to cultural validity. These factors include but are not limited to (1) pathoplasticity
of psychological disorders, (2) cultural factors influencing symptom expression, (3) therapist
bias in clinical judgment, (4) language capability of the client, and (5) inappropriate use of
clinical and personality tests.
1. Pathoplasticity of psychological disorders
Pathoplasticity of psychological disorders refers to the variability in symptoms, course,
outcome, and distribution of mental disorders among various cultural groups. The
pathoplasticity of psychological disorders, therefore, serves as a major threat to cultural
validity in clinical diagnosis resulting from a failure to recognize the cultural plasticity often
associated with various forms of psychopathology.
Studies found that Asian Americans reported a greater severity of mental disorder than
Whites. They also had lower functioning scores, and a higher proportion of psychotic
features among those with mood disorders. However, these studies included participants
who sought mental health services and received a clinical diagnosis; however, there may
have been cultural bias and stereotyping in the diagnostic process. In addition, the studies
were conducted in areas which are more likely to be composed of lower class and less
educated members. Severity of symptoms among Asian Americans remains an unresolved
issue because studies have not yet differentiated between various causal factors.
Moreover, there is evidence that the distribution of mental disorders varies within ethnic
subgroups. The Asian ethnic groups reported the lowest rates of lifetime major depressive
episode, and the highest percentage of psychosis. It is important to examine the interactions
of culture, race, ethnicity, and immigration in the assessment of individuals from diverse
populations.
Three possible causes for the observed higher severity are (1) higher rates of mental health
problems among Asian Americans, (2) underutilization of mental health services, or (3)
misdiagnosis as a result of miscommunication or lack of cultural knowledge.
2. Cultural factors influencing symptom expression
Another threat to cultural validity in clinical diagnosis is the influence of the clients’ cultural
background on their symptom expression.
A study found that Japanese patients expressed more depression, withdrawal, and
disturbance in thinking. Filipino patients exhibited more overt disturbance of behavior and
had more delusions of persecution. Another study found that the behaviors of Japanese
schizophrenia patients changed when they were in hospital. Therefore, in making diagnoses
of Asian Americans, there may be a need to sample their behaviors broadly rather than base
the diagnosis on observations and information obtained only in the diagnostic interview
because cultural background may mediate when and how symptoms are expressed.
, One of the most common claims in cross-cultural psychopathology has been that Asian
Americans tend to somatize distress.
An example is a study on Hwabyung. Because of the Korean culture’s esteem of restraint,
suppression of verbal aggression, and avoidance of confrontation, Hwabyung is a uniquely
Korean culture-bound syndrome in which suppressed emotions manifest themselves
physically. Because of the inappropriateness of and stigma attached to expressing
psychological symptoms, Hwabyung may allow Koreans to deal with life problems by linking
together emotional and bodily distresses in a model congruent with their cultural context.
Another study found that the type of assessment influenced the type and frequency of the
symptoms that the patients reported. Chinese outpatients were found to report more
depressive somatic symptoms in spontaneous report and structured interviews, whereas
Euro Canadian outpatients reported significantly more depressive affective symptoms in all
three assessment modalities. They argued that it is more likely that Westerners
overemphasize the affective or psychological aspects of depression compared with other
cultures. This phenomenon is referred to as the psychologization of depression.
the DSM classification system has received criticisms for its ethnocentricity and lack of
cultural objectivity.
3. Therapist bias in clinical judgement
Therapist bias is the third source of threat to cultural validity in clinical diagnosis. In this
case, therapist bias may be also conceptualized as culture-based countertransference
because the clients’ racial, ethnic, and cultural characteristics are likely to elicit therapist
reactions, which may in turn affect the services provided. Racial or ethnic differences may
affect therapist clinical judgment and assessment such that a therapist may overpathologize
a culturally different client. Problems of misdiagnosis due to therapist bias have been
observed with African Americans, Hispanics, and Asian American. The degree of familiarity
with the patient’s cultural background may influence the diagnostic process.
In a study the White therapists rated the Chinese clients higher on the depression/inhibition
dimension and lower on the social poise/interpersonal capacity dimension than did the
Chinese American therapists. Moreover, the Chinese American therapists judged the White
clients to be more severely disturbed than did the White therapists. Results indicated that
therapists who were ethnically matched with clients provided a higher mental health
functioning score than did therapists who were mismatched.
4. Language capability of the client
Language capability of the client is also a source of threat to cultural validity in assessment
and clinical diagnosis. Language may serve as a barrier to effective therapeutic
communication in several ways. Asian Americans who speak little or no English may be
misunderstood by their therapist. It may interfere with the effective exchange of information
or worse, stimulate bias in the therapist performing the evaluation. There could also be
problems with the use of interpreters, as this may result in distortions that may negatively
influence diagnostic evaluations. The degree of patients’ emotional suffering and despair
may have been underestimated because of distortions by the interpretation process. In
addition, it could also be a problem if the therapist and client do not attach the same
meanings and connotations to words used in diagnosing the patient’s problems.
Key characteristics of both therapists and interpreters are being flexible, open to learning,
and attentive to nuances. in addition, settings that supported less traditional and structured
