The DSM‐IV‐TR and Culture: Considerations for Counselors

According to the American Counseling Association (ACA; 1995), counselor training should contribute to knowledge of different cultural groups, skills in counseling people from diverse cultures, and awareness of one's own stereotypes and biases related to diverse populations (Standards A.2, A.5b, and E.5b). The ACA ethical standards further state that counselors do not discriminate on the basis of age, sex, race, or sexual orientation and that they attempt to increase their personal awareness, sensitivity, and skills with regard to counseling diverse client populations (Standards A.2 and E.5b). To this end, counselor trainees receive training in the cultural foundations of human behavior and how to best counsel people from diverse populations (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2001). Community, family, and mental health counselors, and some school counselors, also receive training on the use of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association [APA], 2000; CACREP 2001 Standards for Community Counselors Section C.5.; CACREP 2001 Standards for Mental Health Counselors Section C.4.). Despite the requirement that counselors receive training in the DSM and in cultural issues related to various aspects of counseling, little literature or research addresses the interface of these two important topics; this lack may lead some to the erroneous assumption that cultural issues do not intersect with counselors' use of the DSM (Castillo, 1997; Lonner & Ibrahim, 2002). (For the purposes of this article, we often refer to the various editions of the DSM as simply the DSM.) However, just as counselors are to display cultural competence when counseling clients (Sue, Ivey, & Pedersen, 1996), it should also be assumed that they must be culturally competent when diagnosing these same clients. Despite the paucity of literature melding culture and the DSM, some researchers have documented the importance of considering cultural issues in psychological assessment and diagnosis (Cofresi & Gorman, 2004; Dana, Aguilar-Kitibutr, Diaz-Vivar, & Vetter, 2002), and several authors have proposed strategies for engaging in culturally sensitive diagnostic practices (DSM-IV-TR; APA, 2000; Castillo, 1997; Eriksen & Kress, 2004; Lonner & Ibrahim, 2002; Mezzich, 1999). For example, the Diagnostic and Statistical Manual of Mental Disorders', fourth edition (DSM-IV; APA, 1994) provides counselors with an outline evaluating clients' cultural contexts. This cultural formulation helps counselors review (a) clients' cultural backgrounds, (b) possible cultural explanations of clients' issues, (c) possible cultural factors related to clients' psychosocial environment and functioning, (d) cultural components affecting the client-counselor relationship, and (e) an overall cultural assessment for proper diagnosis and treatment (Lonner & Ibrahim, 2002; Tanaka-Matsumi, Higginbotham, & Chang, 2002). Mezzich (1999) has further stated that cultural competence with regard to diagnosing entails understanding the cultural framework of the client's identity, cultural explanations of problems, cultural attitudes and perceptions of help-seeking behavior, cultural meanings of adaptive functioning, cultural elements in the therapeutic relationship, and how to provide a thorough cultural assessment. In the professional literature, various possibilities for culturally sensitive appraisal, assessment, and diagnosis have been addressed (e.g., Lonner & Ibrahim, 2002). In this article, we seek to summarize and expand the literature available to counselors by providing counselors with a basic understanding of the criticisms that have been leveled at the DSM system of diagnosis by those sensitive to its impact on nondominant cultural groups. This article also provides guidelines for counselors who use the DSM with people from various cultural backgrounds and who often use Western diagnostic assumptions when diagnosing these clients (Aubrey, 1991). …