TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 196 A firm understanding of clients’ context may lead to a more compassionate and holistic conceptualization of symptoms that could be better explained by contextual factors or environmental stressors (Eriksen & Kress, 2005; Kress & Paylo, 2014). In addition, epidemiological research suggests that psychosocial and environmental problems have moderate predictive value for understanding prognosis of major depression, suicidality, anxiety disorders and substance use disorders (Gilman et al., 2013). Additionally, contextually sensitive counselors define some mental disorders as being a person’s functional attempts to adapt to or cope with a dysfunctional context (Ivey & Ivey, 1999). It is important that any diagnostic discussions integrate a focus on these contextual factors. Culture is an exceptionally important contextual consideration; through culture, clients define, express and interpret their beliefs, values, customs and gender role expectations (Bhugra & Kalra, 2010). Multicultural considerations should enlighten counselors’ diagnostic decisions and ultimately the treatment process. Although it still has room for development, the DSM-5 (2013) includes systematic information regarding gender and culture for each diagnostic category. In some cases, this is limited to a simple accounting of the prevalence of disorders within certain groups; in other cases, APA provided information regarding the diverse presentation or understanding of disorders. Further, the American Counseling Association’s (ACA) Code of Ethics (2014) emphasizes that culture influences manifestation and understanding of problems; thus, counselors must consider culture throughout the counseling and treatment process. Counselors can use formal or informal assessment to explore and understand clients’ context. The DSM-5 includes a Cultural Formulation Interview (CFI) that counselors can use to help them understand clients’ context and its impact on their experiences and symptoms. The CFI may help counselors obtain the most clinically useful information, develop a relational connection with clients and ultimately make accurate diagnoses. The CFI is included in Section III of the DSM-5 and is a semi-structured interview composed of 16 questions that address both individual experience and social context. The text is divided into two columns, with counselor- generated questions on the right and instructions for application on the left. Two versions of the interview are available, one for the individual and one for an informant (e.g., a caregiver or a parent). The interviews also are available online at the APA’s (2014) DSM-5 website. The CFI also includes 12 Supplementary Modules, which provide additional questions used to assess domains of the 16-item CFI (e.g., cultural identity) as well as questions that counselors can ask during the cultural assessment of particular groups (e.g., children and adolescents, older adults, immigrants and refugees, and caregivers). Should counselors elect not to use this more formal interview format to assess culture, there are multiple additional formal and informal cultural assessments as well as assessment guidelines that they can apply. For example, Castillo (1997) provided the following guidelines for culturally sensitive diagnosis: (a) assess the client’s cultural identity; (b) identify sources of cultural information relevant to the client; (c) assess the cultural meaning of a client’s problem and symptoms; (d) consider the impacts and effects of family, work and community on the complaint, including stigma and discrimination that may be associated with mental illness in the client’s culture; (e) assess for counselor personal biases; and (f) plan treatment collaboratively. Castillo’s guidelines offer a comprehensive assessment that may inform diagnostic practices. The ACA’s Code of Ethics (2014) also indicates that counselors should recognize social prejudices that lead to misdiagnosis and overpathologizing of certain populations. It is impossible to understand clients’ unique situations and how to best help them if cultural considerations are not addressed. An understanding of clients’ culture in relation to diagnosis includes understanding cultural explanations of their experiences, their help- seeking behavior, the cultural framework of clients’ identity, cultural meanings of healthy functioning and cultural aspects that relate to the counselor–client relationship (Eriksen & Kress, 2005).