I have just been assigned to see a client who is from a culture that is completely unfamiliar to me. She immigrated to the U.S. three years ago and speaks English, but I’m concerned about being able to do psychotherapy with her. How can I make sure I don’t over diagnose symptoms that may have a different cultural meaning for her than for my other clients?
It’s good that you’re aware of the importance of your client’s culture in your diagnosis and psychotherapy. When working with a client whose culture is unfamiliar to you, I recommend doing some research into the culture to learn some basic facts about her country of origin. If you haven’t worked with other individuals who are recent immigrants, doing research into this area will also be valuable. However, also remember that your client is the best person to educate you about herself. She is presenting for behavioral health treatment because she is in distress and wants help with some issues that are troubling her. The skills you use in the first session with any client will serve you well in this situation. In addition, you may want to ask her how her family members or friends in her country of origin would understand or interpret her symptoms to provide some cultural context for her concerns.
One way to keep the cultural context in mind when using the DSM for diagnostic purposes is to ask about events leading up to the client’s immigration and conditions since she arrived in the U.S. It is possible that an adjustment disorder or posttraumatic stress disorder diagnosis may be appropriate. If her symptoms don’t fit either of these diagnoses, you can use an initial “not otherwise specified” or provisional diagnosis, which will note your lack of sufficient information to make a full diagnosis. This can be changed as you learn more about her history and current life circumstances.
Another way to use the DSM as a resource for assessment is to incorporate the cultural formulation found in Appendix I of the DSM-IV and in Section III of the DSM-5. The outline for cultural formulation includes cultural identity, cultural conceptualization of distress, psychosocial stressors and supports, and cross-cultural features of the treatment relationship. The DSM-5 also includes a set of interview questions that can be used in assessing the cultural context of the client’s clinical presentation.
A final issue to consider in your initial assessment and ongoing psychotherapy is the cultural context of your role as a professional in the therapeutic relationship. If you are still in training, you may not think of yourself as an expert, and many of your U.S. born clients may treat you as a peer or make comments about your status as an intern or trainee. Many other cultures hold a value of deference to authority, however, and this may make your client reluctant to disagree with you or to express her preferences about the treatment. In addition, recent immigrants and other cultural groups often have experiences of discrimination and misunderstanding by officials, administrators and service providers. It can be helpful to directly express your interest in the client’s ideas, to ask open-ended rather than closed questions, and to acknowledge the extent and limitations of your knowledge. Even so, it may take more time to develop a therapeutic alliance with this client than with clients who are from cultural backgrounds similar to yours.
I hope you find this blog helpful in working cross-culturally. Please email me with comments, questions or suggestions for future blog topics.