Assessing and Treating Culturally Diverse Clients: A Practical Guide

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Freddy A. Paniagua

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  • Dedication

    To the memory of my brother, Rhadames Antonio Paniagua Arias (1946–2012), and Dr. Israel Cuéllar (1946–2008), a colleague and member of my extended family

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    Series Editor's Foreword

    The continuing theme of the SAGE Publications book series Multicultural Aspects of Counseling and Psychotherapy has been the importance of providing practical information of immediate value to readers. This contribution to the series is an excellent example of how a book can be practical and still not oversimplify complex issues.

    This fourth edition of Assessing and Treating Culturally Diverse Clients: A Practical Guide continues Freddy Paniagua's impressive contribution to the research literature on culture and counseling therapy. This edition breaks new ground in its expanded coverage of contemporary and controversial topics. It helps to prepare clinical and counseling providers for a future in which the standards of multicultural competence will become more important than ever before.

    In prior editions, this book provided for the first time in the multicultural literature a discussion of the significance for the clinical context of the demographic trends found in the 2000 U.S. Census, which has been extensively revised in this edition with the 2010 U.S. Census. By covering the demographic changes that have taken place both within and among the four ethnic groups discussed here relative to the majority culture, this book helps to prepare clinical and counseling providers for the clients they can expect to see in the future.

    This edition also includes expanded coverage of acculturation issues that encompasses discussion of four different models of acculturation and their applicability in clinical contexts. The problems associated with varying levels of acculturation are particularly relevant to clinical and counseling providers, who will be expected in the near future to provide services to a rapidly increasing number of clients who do not speak English. At present, few of those providers are prepared for this future.

    The solid chapters found in the first three editions providing guidelines for the assessment and treatment of African Americans, Hispanics, Asians, and American Indians have been updated and refocused with regard to demographic trends and the complexity of within-group differences. Practical suggestions for dealing with hot-button issues in each ethnic context are specified in ways that will help providers avoid and prevent unnecessary problems.

    This edition also includes two new chapters for mental health professionals searching for practical guidelines regarding counseling culturally lesbian, gay, bisexual, and transgender (LGBT) and older adults. These chapters follow the traditional practical approach in prior editions, namely, avoiding theoretical discussions and emphasizing practical guidelines mental health professionals can use when assessing, diagnosing, and treating culturally diverse clients from the LGBT and older communities.

    This edition also includes discussion of the use of the mental status exam along with case vignettes that illustrate the practical value of providers' attending to issues of cultural competence. Each component of this exam is illustrated with culturally appropriate examples. Another feature of this volume is an extensive discussion of recent empirical findings that support arguments concerning racism's influence on the reported prevalence and incidence of mental disorders among clients from the four ethnic groups addressed here.

    All three editions of this book have made very successful contributions to the multicultural counseling literature. Large numbers of providers and consumers have benefited from the practical suggestions offered in each edition, and each edition has clarified complex issues of assessment, diagnosis, and treatment in multiethnic contexts with minimal rhetorical, theoretical, or philosophical complications. The immediate, practical importance of multicultural competence has been a prominent theme in all three editions. Perhaps that is why this book is listed among the 100 bestselling books in counseling for 2004.

    Of all the books in the Multicultural Aspects of Counseling and Psychotherapy series, Freddy's book does the best job of helping clinicians use diagnostic tools in practical and meaningful ways. This book reaches out to well-intentioned clinicians who are seeking to become more intentional in providing mental health services to their culturally diverse clients. It is with great pride that we include this fourth edition of Assessing and Treating Culturally Diverse Clients among the other books in this series.

    PaulPedersen, Professor Emeritus, Syracuse University, Visiting Professor, University of Hawaii Department of Psychology

    Preface

    Why This Book Was Written

    Four of the major multicultural groups that mental health practitioners see in the United States are African Americans, American Indians, Asians, and Hispanics. An important task for practitioners across all mental health disciplines (psychology, psychiatry, social work, family therapy, and the like) is to learn and apply skills that indicate that they are culturally competent in the assessment, diagnosis, and treatment of clients from these groups (Ponterotto, Casas, Suzuki, & Alexander, 2010; Pope-Davis & Coleman, 1997). Relevant questions concerning the mental health assessment, diagnosis, and treatment of multicultural clients include the following:

    • What should a practitioner do during the first meeting or session with an African American client versus an Asian client?
    • Should a practitioner treat an American Indian client with the same therapeutic approach used with a Hispanic client?
    • What exactly should a practitioner do differently in assessing, diagnosing and treating members of different cultural groups?
    • What are some examples of cross-cultural skills a practitioner should display to minimize bias in the assessment and diagnosis of clients from different cultural groups?
    • What specific culturally competent skills should a practitioner have to identify bias in the epidemiological mental health literature?

    Not only are questions such as these clinically relevant, but a practitioner's failure to answer them and to demonstrate knowledge of the answers in clinical practice may be considered an example of a lack of cultural competence and violation of ethical principles (LaFromboise, Foster, & James, 1996). For example, the American Psychological Association's (2010) code of ethics states that a mental health professional should be “aware of and respect cultural, individual, and role differences, including those based on age, gender identity, race, ethnicity, culture, national origin, religion, disability, language, and socioeconomic status [emphasis added], and consider these factors when working with members of such groups” (p. 4). Violations of this principle may be considered to be either cases of unfair discriminatory practices or the need for the practitioner to engage in cultural competency training with emphasis on such factors. In addition, the written and oral exams required for licensure in the practice of psychology, psychiatry, social work, and other mental health professions include items designed to measure test takers' understanding and application of cultural variables that might have impacts on their assessment, diagnosis, and treatment of individuals from multicultural groups seeking mental health services.

    An excellent literature is available to help mental health practitioners in the development and application of cross-cultural skills in their clinical contacts with multicultural clients (Bamford, 1991; Berry, Poortinga, Segall, & Darsen, 1992; Comas-Díaz, 1988, 2012; Comas-Díaz & Griffith, 1988; Dana, 1993a; Gaw, 1993a; Ho, 1992; Koslow & Salett, 1989; Lefley & Pedersen, 1986; McAdoo, 1993a; Pedersen, 1987, 1997; Ponterotto, et al. 2010; Seijo, Gomez, & Freidenberg, 1991; Sue & Sue, 2003; Tharp, 1991). In many cases, however, practical guidelines concerning the assessment, diagnosis, and treatment of individuals from various cultural groups are either dispersed across the literature (e.g., Comas-Díaz, 2012; Dana, 1993a; Koslow & Salett, 1989; Ponterotto et al., 2010) or mixed with discussions of philosophical, political, and theoretical issues regarding the assessment and treatment of such groups (e.g., Berry et al., 1992; Sue & Sue, 2003). Practitioners interested in self-training to improve their cultural competence in the assessment, diagnosis, and treatment of multicultural groups previously have not had available one comprehensive text that takes an integrative approach and summarizes existing guidelines. In addition, the discussion of multicultural issues in mental health practices (particularly in the areas of assessment, diagnosis, and treatment) has been evolving rapidly; practitioners may have a difficult time keeping up with this discussion while engaging in their routine clinical practices. Similar to prior editions of this text (Paniagua, 1994, 1998, 2005), my main goal in this edition is to provide mental health practitioners with an integrative and practical source that will help them understand exactly what they should do or not do to demonstrate cultural competence and avoid unfair discriminatory practices during the assessment, diagnosis, and treatment of African American, American Indian, Asian, and Hispanic clients. In this edition, two chapters have been added to address multicultural issues faced by clients from the lesbian, gay, bisexual, transgender, and older communities.

    Overview

    It is important to note that the descriptions of cultural variables provided in this book reflect generalizations; any given characterization may not be true for all members of a group (e.g., Asians) or for all groups within a given group (e.g., in the case of Hispanics, the subgroup of Cubans versus the subgroup of Mexican Americans). As Sue and Sue (2003) note, it is erroneous to believe that all African Americans are the same, that all Hispanics are the same, that all Asians are the same, or that all American Indians are the same. Differences within these groups and across subgroups exist in terms of primary language (particularly among Asians), generational status (e.g., early versus later immigrants), acculturation, and socioeconomic status (Ponterotto et al., 2010; Sue & Sue, 1987, 2003). The members of these groups, however, do share some cultural variables that are often considered to be relevant in the assessment, diagnosis, and treatment of all members of non-Anglo-American cultural groups, regardless of group identity (e.g., all tend to place special importance on family relationships and to emphasize the extended family rather than the nuclear family). Such shared cultural variables across diverse groups and subgroups might be termed “cultural commonalities” (Chung, 1992). In this volume, I provide summaries of cultural commonalities that exist across groups (Chapters 2, 7, 8, and 9) and within subgroups (Chapters 3, 4, 5, 6, 10, and 11) that practitioners can use to guide their clinical practices with African American, Hispanic, Asian, and American Indian clients.

    Chapter 1 offers a tentative explanation for the growing use of the terms multicultural and diversity, and the decreasing use of the term minority in the literature. Data gathered in the most recent U.S. Census serve to illustrate this point. Chapter 1 also includes a brief discussion on the distinction between race and ethnicity, which is still a controversial issue in the multicultural literature.

    Chapter 2 presents an overview of general guidelines regarding the development of a therapeutic relationship with regard to the four culturally diverse groups discussed in this text. Chapter 2 has been enhanced with the introduction of new materials in several sections. For example, the discussion dealing with the cultural compatibility hypothesis versus the universalistic hypothesis in establishing the development of a therapeutic relationship between the client and the therapist has been expanded. In addition, the section on overdiagnosing of multicultural groups has also been enhanced with new materials and updated references. Furthermore, the sections dealing with different models of acculturation and their applications in clinical contexts, as well as the discussion on using data from the 2010 U.S. Census in the clinical contexts have been substantially expanded with new materials and updated references. The construct of acculturative stress is also introduced and defined in this chapter. Chapter 2 also includes two new sections. The first newly added section involves guidelines clinicians should consider when selecting translated psychological tests. The second is a discussion on social class, classism, and mental health based on Liu's (2011) excellent work on this subject.

    Chapters 3, 4, 5, and 6 provide updated overviews of demographic characteristics of African Americans, Hispanics, Asians, and American Indians, respectively. As in prior editions, across these chapters, three sets of practical guidelines for each group are discussed: guidelines on cultural variables that may affect assessment, diagnosis, and treatment; guidelines for the first session; and guidelines for conducting psychotherapy in subsequent sessions. Across each of these sets of guidelines, substantial revisions have been made with emphasis on new materials from the multicultural literature that appeared after the publication of the last edition of this text (Paniagua, 2005). Chapter 3 now includes a table (Table 3.1) to help clinicians with an understanding of the distribution of African American alone or in combination with other races across several major cities in the United States and regions (e.g., the Northeast versus the Midwest). Chapter 4 includes a new discussion on the use of dichos (proverbs) in the treatment of Hispanic clients. In addition, this chapter now includes the 28 cities (Table 4.2) in the United States (instead of 10 as in the prior edition of this text) with the highest percentages of Hispanic population reported in the 2010 U.S. Census. Table 4.2 should assist clinicians interested in serving this group with the screening of cities where they are expected to serve a large portion of Hispanics seeking mental health services. A similar table (Table 5.2) has been added in Chapter 5, for the same purpose with Asian populations. In addition, Table 5.1 is new and provides information regarding the largest number of Asian groups in the United States. Chapter 5 also includes two new sections: acculturation and acculturative stress and the need for clinicians to consider indigenous healing approaches in addition to conventional or Western therapy approaches.

    In addition to substantial revision in Chapter 6, exploring the level and models of acculturation (described in Chapter 2) during the first session with American Indian clients has been added. Two new tables have been added to this chapter. These tables should assist clinicians with the screening of the largest number of American Indian and Alaska Native alone or in combination with other groups in several states and regions in the United States (Table 6.1) and an understanding of the largest American Indian reservations (Box 6.1). Practical guidelines to help practitioners to understand and prevent attrition among clients from the target groups are summarized in new tables in Chapters 36. Chapter 2 includes Box 2.2, dealing with general guidelines to prevent attrition in the present context.

    Chapter 7 is intended to assist practitioners to critically review and evaluate the epidemiological research that has been conducted concerning the prevalence and incidence of mental disorders among members of the four groups discussed throughout this text. An important addition to Chapter 7 in this new edition is an extended discussion regarding the association between English-language proficiency and psychopathology, which is a controversial area practitioners should understand to prevent overdiagnosing or misdiagnosing clients, particularly in the case of Asian and Hispanic clients, as well African American clients who elect to use nonstandard English during the assessment and diagnostic process.

    Chapter 8 makes an obvious point: that most measures or assessment instruments used today by mental health practitioners with African American, American Indian, Asian, and Hispanic clients are culturally biased. For various practical reasons, however, it may not be advisable to recommend that practitioners stop using these measures. A better alternative would be to train practitioners (and also graduate students) to use culturally biased measures in ways that will not harm their multicultural clients. Practitioners need to know how to recognize the biases that exist in the measures they use and how to evaluate the data they gather accurately and appropriately so that it is meaningful and helpful to them in their work with culturally diverse clients. In Chapter 8, the discussion of the effects of racism as an explanation for the prevalence and incidence of mental disorders in members of some groups has been expanded with a distinction between racism as a stressful event leading to the development of mental disorders and racism as an explanatory construct for the prevalence and incidence of mental disorders. The DSM-IV-TR (American Psychiatric Association, 2000) endorsed the term culture-bound syndromes in response to the use of this term in the multicultural literature. DSM-5, however, removed this endorsement of that term and replaced it with three cultural concepts—cultural syndromes, cultural idioms of distress, and cultural explanations or perceived causes (American Psychiatric Association, 2013). This removal of the culture-bound syndromes term in the DSM-5 is reviewed in Chapter 8, including a discussion regarding reasons for keeping this term in the cross-cultural literature.

    With the release of the DSM-5, the American Psychiatric Association again encourages clinicians (as was the case in the DSM-IV-TR) to pay attention to the potential role of specific cultural variables in the clients' presentation of symptoms across most psychiatric disorders described in the manual. Several DSM-5 drafts included over 2,300 responses from all sections of the mental health field and the public sector. These responses were generally associated with critiques related to changes in current diagnosis and/or the addition of new mental disorders. Although attention to cultural variables in the DSM-5 was not a crucial issue in such critiques, it is important to emphasize that the DSM-5 greatly expanded discussions on cultural variables across most mental disorders, relative to discussion of such variables in the DSM-IV-TR (American Psychiatric Association, 2000). Chapter 9 has been extensively revised in response to substantial additional cultural contributions in the DSM-5. In Chapter 9, busy clinicians are rewarded with a rapid review of important cultural issues they should consider when making a DSM-5 diagnosis of mental disorder. This quick review is particularly significant in the case of new mental disorders in the DSM-5, as well as the addition of the DSM-5 Cultural Formulation Interview (CFI), which practitioners can use to screen the impact of the client's culture on critical areas of assessment and diagnosis of mental disorders. Chapter 9 also discusses the current scholarly controversy regarding using DSM-5 versus the International Classification of Diseases in the diagnosis of mental disorders. This chapter also expands the discussion on conditions that may be the focus of clinical attention, particularly with the addition of new V Codes in the DSM-5 that are culturally relevant when assessing and diagnosing DSM-5 mental disorders.

    Two new chapters have been added to this edition. Chapter 10 provides counseling guidelines for culturally diverse lesbian, gay, bisexual, and transgender (LGBT) clients. Chapter 11 is devoted to counseling guidelines for culturally diverse older adult clients. Both chapters emphasize the tradition in prior editions of this book, namely, avoiding theoretical discussions and more emphasis on practical guidelines clinicians can use when providing mental health services to culturally diverse clients from the LGBT and older communities.

    This book was first published 19 years ago (1994), and this edition reflects issues in the multicultural field that have been fairly consistent across those years (e.g., the impact of acculturation and racism on assessment, diagnosis, and treatment of mental disorders), as well as new developments in this field including more insights into the relationship among the constructs of social class classism and mental health; the impact of acculturative stress in the development of symptoms of mental disorders; and new instruments to assess acculturation, perceived ethnic/racial discrimination, and introduction of the Cultural Formulation Interview in the DSM-5.

    Acknowledgments

    I am indebted to many individuals whose support and advice played a major role in the preparation of this book. I want to thank F. M. Baker (University of Maryland) and Sharon Nelson Le-Gall (University of Pittsburgh) for their review of Chapter 3 (African Americans) and valuable suggestions. (The affiliations mentioned here, and those below, reflect the affiliations of these individuals at the time of the publication of the first edition of this book in 1994. The current revision of this book still reflects their core editorial and scholarly suggestions.) Richard H. Dana (Portland State University) reviewed the guidelines involving the use of the epidemiology of mental health literature with multicultural groups (Chapter 7) and the guidelines concerning the use of culturally biased instruments (Chapter 8). He sent to me an extensive commentary regarding ways to improve these chapters, and I am grateful to him for his comments. Derald W. Sue (California State University at Hayward) and Anh Nga Nguyen (University of Oklahoma Health Sciences Center) assisted me with Chapter 5 (Asians), and I also want to thank them for their comments. Derald W. Sue also reviewed Chapter 2 (general guidelines); I particularly thank him for updating the references on Asian Americans. I thank Stanley Sue (University of California, Los Angeles) for reviewing portions of Chapters 1 and 2, particularly in relation to the discussion on cultural mismatch and racial mismatch.

    Arthur McDonald (president, Dull Knife Memorial College, Montana) reviewed Chapter 6, and I wish to thank him for making me aware of several sensitive issues in the assessment and treatment of American Indian clients. Lillian Comas-Díaz (independent practice, Washington, DC) made substantial revisions regarding guidelines in the assessment and treatment of Hispanic clients (Chapter 4), including translation of terms from English into Spanish, a better interpretation of the acknowledgment of spiritual issues by Hispanic clients during the first session, and the enhancing of the bibliography dealing with the assessment and treatment of Hispanic clients. I thank her for her effort and time in revising these materials.

    Sylvia Z. Ramirez (University of Texas at Austin) and Sylvia Linares were clinical fellows under my supervision at the time I was organizing my thoughts to write this book. I discussed many of the topics in this text with them, and I thank them for their suggestions. I also want to thank Sylvia Ramirez for reviewing Chapters 4 and 8 as well as for her suggestion to include additional cultural variables leading to a better understanding in the assessment and treatment of Hispanic clients. Victor L. Tan and Angela S. Lew were clinical fellows under my supervision at the time I wrote Chapter 9, and I want to thank them for their comments and suggestions to improve this chapter.

    Before Israel Cuéllar (University of Texas-Pan American University at Edinburg) lost his battle with amyotrophic lateral sclerosis (ALS) in 2008 (Zamarripa, 2009), I spent many hours discussing cross-cultural issues with him, particularly his contributions in the acculturation literature. Cuéllar was the first person (as far as I can remember) who encouraged me to write this book. He reviewed Chapters 4, 8, and 9. I deeply thank him for his comments and suggestions on how to improve these chapters.

    John D. Robinson (Howard University Hospital/College of Medicine, Washington, DC) reviewed Chapter 10, and David Chiriboga (University of South Florida) reviewed Chapter 11. They provided extensive scholarly suggestions to ensure that these chapters reflect the current literature with emphasis on LGBT and older adults. I thank them for their review.

    I have also spent a significant number of hours over the past 27 years discussing cultural issues with Charles E. Holzer III (University of Texas Medical Branch at Galveston), and his expertise in psychiatric epidemiology has been extremely valuable to me, particularly with the preparation of Chapter 7.

    I thank Paul Pedersen, the series editor, who was instrumental in the final preparation of this book for publication in 1994, 1998, and 2005. He spent many hours reading each chapter in prior editions of this book and making sure that the book reflects practical guidelines for clinicians interested in the assessment and treatment of multicultural groups and that the book contains minimal rhetoric about multiculturalism. Pedersen's comments on prior editions of this book are still valid for this edition.

    Reviews of the first three editions of this book have been very encouraging, and I have used the critiques that have been offered to correct several comments.

    I also want to thank the staff of SAGE Publications for their time and effort in the preparation of this edition. I particularly want to thank Kassie Graves (senior acquisitions editor, Human Services) and Stephanie Palermini (production editor, Books). Dan Gordon is a freelancer for SAGE, and I also want to thank him for his copy-editing support across chapters.

    I want specially to thank Sandra A. Black (Sam), and my son Robert Alexander Paniagua (Rap) for their support and patience throughout the completion of this book.

    Finally, I want to note that I recognize that the topics addressed in this book are extremely sensitive and that I am responsible for any errors or misunderstanding readers may find in the text. As in prior editions of this volume, I will deeply appreciate any comments and suggestions that readers may send to me, and I will consider all readers' feedback as I prepare future printings and editions of this book. Please send your comments to me care of SAGE Publications, 2455 Teller Road, Thousand Oaks, California 91320.

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    Author Index

    About the Author

    Freddy A. Paniagua (PhD, University of Kansas, Lawrence, Kansas; postdoctoral training at Johns Hopkins University School of Medicine) is a retired tenured professor and currently an adjunct professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical Branch (UTMB) at Galveston, where for more than 20 years he has taught cross-cultural mental health seminars with an emphasis on the assessment, diagnosis, and treatment of African American, American Indian, Asian, and Hispanic clients. In 2009–2010, he was associated with the Faculty Research Participation Program at the U.S. Public Health Command (USPHC) administered by the Oak Ridge Institute for Science and Education (ORISE), assigned to the Behavioral and Social Health Outcomes Program (BSHOP), Aberdeen Providing Ground, with emphasis on research on suicide in the U.S. Army. In 1989, he received a six-year training grant from the National Institute of Mental Health to provide postdoctoral and post–master's degree training to mental health professionals representing different multicultural groups, with emphasis on the assessment, diagnosis, and treatment of emotionally disturbed clients. He has published more than 40 scientific articles, including basic and applied research, theoretical contributions, and three textbooks on multicultural issues widely used in mental health training programs in the United States and abroad.


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