Promoting the Cu Itu ral ly Sensitive Diagnosis of Mexican Americans:

Some Personal Insights

Myra Gonzales ldalia Castillo-Canez

Henry Tarke Fernando Soriano

Piedad Garcia Roberto J. Velasquez

This article presents a series of personal guidelines for promoting the cul- turally sensitive psychiatric diagnosis of Mexican American/CNcano clients. These guidelines are primarily based on the authors' collective experiences in diagnosing and treating this population.

Diagnostic assessment can be especially challenging when a clini- cian from one ethnic group uses the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-Tv; American Psychiatric As- sociation, 1994) to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual's cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or ex- periences that are particular to the individual's culture (DSM-N 1994). The purpose of this brief article is to present some of our personal

insights into the psychiatric diagnosis of Mexican American or Chicano clients. These insights are intended to (a) supplement those made by other clinicians who have previously examined issues related to

M g r a Gonzales is a doctoral student in counseling psychology at Michigan State University. Zdalia Castillo-Canez is a graduate student in clinical psychology at San Diego State University. Henry Tarke is regional manager of San Diego Mental Health Services. Fernando Soriano is a research associate for the Child and Family Research Group in San Diego. Piedad Garcia is regional manager for San Diego Comty Mental Health Services. Roberto J. Velasquez is an associate professor of Psychology at San Diego State University. Correspondence regarding this arlicle should be sent to Myra Gonzales, Michigan State University, 11 2 Paolucci Bldg., E. Lansing, MI 48824-1 11 0.

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the diagnosis of the greater Hispanic population including persons of Mexican descent (e.g., Cervantes & Arroyo, 1994: Mezzich & Saavedra, 1994: Oquendo. Horwath. & Martinez, 1992: Velasquez. Johnson, & Brown-Cheatham, 1993). (b) promote the culturally sensitive application of the DSM-N( 1994) to this population, and (c) challenge counselors to reexamine their personal diagnostic frame- works, which include biases and stereotypes. to ensure competence and to lower the risk of misdiagnosis. Initially, it is important for us to note that some of the observations

we allude to, including the role of language in the expression of psychopathology. have received significant attention in the research literature (Malgady. Rogler, & Constantino. 1987). That is. these ob- servations are not simply anecdotal or "gut reactions" but are sup- ported in the literature.

1. Counselors must recognize that Mexican American clients, like all clients, are eligible for a variety of diagnoses found in the MM-N. In our many years of supervising counselors, we have observed that many clinicians become easily accustomed (or attached) to the diag- noses they believe are most prevalent in the Chicano population. In fact, these diagnoses may vary, and include conduct disorder, oppo- sitional defiant disorder, separation anxiety disorder, and reactive attachment disorder for children and adolescents (Cervantes and Arroyo, 1994): and generalized anxiety disorder, schizoaffective dis- order, borderline intellectual functioning, dependent personality dis- order, schizoaffective disorder, borderline intellectual functioning, dependent personality disorder, and antisocial personality disorder for adults (Velasquez et al., 1993). Our review of client files at several community mental health centers throughout the Southwest sup- port these various types of diagnostic patterns and practices. The inherent danger of assuming that the majority of Chicano cli-

ents possess a limited group of mental disorders is tantamount to believing that all members of this population possess identical char- acteristics. Another danger is that counselors wil l apply the same mode of treatment to all Mexican American clients with similar (or assumed) psychiatric diagnoses. We strongly encourage counselors to understand the variety of mental disorders that are in the DSM- n! and to consider the fact that Mexican American clients may present a variety of disorders that reflect their clinical issues. Avoid using stereotyped mental disorders of Chicanos. 2. Counselors must recognize that Mexican American clients may

not have the same mental disorders as African American or Asian American clients. Although this observation may seem obvious, there

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many counselors who assume that all identified ethnic minority groups have the same mental disorders or problems because of a shared minority status. That is. they assume that risk factors such as poverty, racism and discrimination, low educational attainment, unemployment, immigration, and linguistic barriers cause the same mental disorders in all ethnic minority groups. The reality is that each group has its own unique mode (i.e., adaptive or maladaptive) of responding to each or all of these factors. The common diag- noses in many mental health clinics that cater to multicultural populations is generalized anxiety disorder, major depression, or hypochondriasis. 3. Counselors must recognize that an acculturation problem,

although a V code in the DSM-N; is a condition that sometimes natu- rally accompanies many disorders in Mexican Americans. Counse- lors tend to minimize the value of this category in the overall diag- noses of Chicanos. Because an acculturation problem is a V code, we have seen counselors, who ignore V codes, frequently underuse this particular category in their diagnoses of Chicanos. We recommend that counselors view the presence of mental disorders in this popu- lation from the perspective that their origin may be directly linked to the acculturative stress that occurs in adjusting to the norms of this society. We suggest that an acculturation problem may be used as a specifier or modifier to disorders such as dysthymia. brief psychotic disorder, schizophrenia, or adjustment disorder. 4. Counselors must recognize that the potential for culture bound

syndromes in Mexican American clients is quite real. As with an acculturation problem, we have seen the general underutilization of culture bound syndromes by counselors in the diagnosis of Chi- canos. Counselors assume that the only clients who may qualify for a culture bound syndrome, such as ataques de neruios or susto, are those who have immigrated from other parts of Latin America, in- cluding Mexico. Counselors may assume that tenth generation Chi- canos from New Mexico could never possess such a disorder be- cause they were born in this country, or because they are not expe- riencing acculturative stress. We recommend that counselors consider the possibility of a cul-

ture bound syndrome in clients who do not seem to meet any of the criteria for a specific disorder. It may be that a client who is expe- riencing a sudden change in behavior, a dissociative experience, screaming, or brief psychotic symptoms may be experiencing ataques de neruios instead of schizophrenia or major depression (Oquendo et al.. 1992). Instead of simply trying to fit a Mexican American cli- ent into a particular disorder, either out of frustration or for the

sake of expediency, we advocate for the consideration of culture bound syndromes in the decision-making schema of all counselors. We do recognize a major limitation to the current use of culture bound syndromes is the absence of diagnostic criteria that describes the intensity, frequency, and duration of specific syndromes. Oquendo et al. (1992) were some of the first to articulate a possible criteria for ataque de nemios. 5. Counselors must recognize that many DSM-Wdisorders in Mexi-

can American clients, like clients from other ethnic/cultural groups, may be temporary and not permanent. We have observed many situ- ations in which counselors assume that a psychiatric diagnosis automatically implies a long-term or trait-like condition, or what has come to be known as a label. Clearly, this type of assumption is dangerous because the counselor can potentially view the Mexican American client as chronic, limited, without resources, or with a poor prognosis. 6. Counselors must recognize the prominent role that language

plays in the expression or psychopathology in Mexican American clients (Cuellar, Martinez, Jimenez, & Gonzales, 1983; Fabrega. 1995). This includes (a) the spec& language of the client (English- or Spanish- speaking, or bilingual), (b) the idioms of distress that are used by these clients, especially in Spanish (e.g., Zocura [craziness], descontrolado. chiflado. desorientado [disoriented]). and (c) the lan- guage in which the client is evaluated by the counselor. All of these, singly or in concert with each other, form a rather complex and multilevel medium of expression that must be addressed by the coun- selor. For example, we have observed that many bilingual clients tend to use English and Spanish idioms interchangeably as a means of describing the essence of their problems or concerns. Counselors must be attuned to this type of communication pattern and not consider this as dysfunctional or as 'simply another symptom of a particular DSM-W disorder."

7. Counselors must recognize that the psychiatric diagnosis of Mexican American clients, like that of other clients, is multidimen- sional. We have observed that many counselors who evaluate Chicano clients tend to focus all of their attention on either Axis I or I1 while disregarding the importance of the remaining axes. For example, we consider Axis IV to be very important for Mexican American clients because a counselor can identify key psychosocial and environmen- tal problems that can help clanlfy the presence of an Axis I and I1 disorder. These can include language barriers, discrimination, vio- lence, immigration stress, homelessness, and so forth. The same can be said about Axis V s Global Assessment of Relational Func-

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tioning Scale (GARF). This scale can be used by counselors as a contextual template when evaluating this population. The scale is intended to assess problem solving abilities (e.g.. ability to resolve conflict), organization (e.g., boundaries and coalitions), and emo- tional climate (e.g.. empathy, involvement). We have found this scale to be invaluable to understanding the role of hafamilia (the family) in the client's life. 8. Counselors should consider using the DSM-N "cultural formula-

tion" with every Mexican American client. This formulation takes into consideration the cultural identity of the client (e.g., degree of involvement with both the culture of origin and host culture), the cultural explanations of the client's illness (e.g.. idioms of distress or cultural interpretations), the cultural factors related to the psy- chosocial environment including social support, the cultural element of the relationship between the client and the counselor (e.g., cultural and linguistic barriers between the counselor and cli- ent), and the overall assessment for diagnosis and care.

FINAL REMARKS

In this article, we have provided some of our personal insights about the psychiatric diagnosis of Mexican American/Chicano clients. Al- though this is not a definitive listing of all of the issues counselors must consider when diagnosing this population, we have discussed some of the most salient issues. We, like Kirk and Kutchins (1992). believe that counselors must possess a healthy skepticism about the process. or business of diagnosis, and not take for granted a system that continues to have many limitations. I t is important to recognize that diagnosis for ethnic minority populations can have social, economic, and political implications.

REFERENCES

American Psychiatric Association (1994). Diagnostic and statistical manual of men- tal dborders (4th ed.). Washington. DC: Author.

Cervantes, R C.. & Arroya, W. (1994). DSM-N: Implications for Hispanic children and adolescents. Hispank Journal of Behavioral Sciences, 16, 8-27.

Cuellar, I., Martinez, C.. Jimenez. R.. & Gonzales, R. (1983). Clinical psychiatric case presentation: Culturally responsive diagnostic formulation and treatment in a Hispanic female. Hispanic Journal of Behavioral Sciences, 5.93-103.

Fabrega. H. (1995). Hispanic mental health research: A case for cultural psychiatry. In A. M. Padflla (Ed.), Hispank psychology: C m a l issues in theory and research (pp. 107-130). Thousand Oaks, CA: Sage.

Kirk. S. A, & Kutchins, H. (1992). The seUfrg of DSM: The rhetoric of science in psychhtnj. New York: De Gruyter.

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Malgady, R., Rogler, L. H., & Constantino, G. (1987). Ethnocultural and linguistic bias in mental health evaluation of Hispanics. American Psychologist, 42, 228- 234.

Mezzich. J. E., & Saavedra, J. (1994). DSM-IV development and Hispanic issues. In C. Telles & M. Karno (Eds.), Latino mental health. Current research and policy perspectbes (pp. 170-180). Los Angeles: UCLA Neuropsychiatric Institute.

Oquendo. M.. Horwath. E.. & Martinez. A. (1992). Ataques de nervios: Proposed di- agnostic criteria for a culture specific syndrome. Culture, Medicine and Psychiatry,

Velasquez, R. J., Johnson, R., & Brown-Cheatham, M. (1993). Teaching counselors to use the DSM-UI-R with ethnic minority clients. Counselor Education and Super- vision. 32. 323-33 1.

16, 367-376.

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