In clinical practice, the distinction between psychopathological conditions and culture-related situations might be difficult to apply for three reasons (Paniagua, 1998). First, managed care companies, Medicaid, and Medicare are demanding a significant reduction in the number of sessions with clients seeking mental health services, and the overall expectancy is that the first session (approximately 45 minutes to one hour) would be devoted to the assessment of the case and diagnosis of symptoms, whereas the majority of sessions (generally six sessions, one hour per session) would be used to treat these symptoms. Under this restriction, clinicians would not have enough time to differentiate psychopathological conditions unrelated to a specific cultural context from psy-
chopathology associated with a given cultural context. For example, many Asian clients believe that emotional problems bring shame and guilt to the Asian family, preventing these clients from reporting such problems to others outside the family during the first session (Paniagua, 1998; Sue & Sue, 1990). Under this condition, it would be extremely difficult to conclude that the intense anxiety an Asian client is experiencing during the first session is an example of the culture-bound syndrome "horo" (Castillo, 1997; Chowdhury, 1996; see Table I).
Second, assuming that clinicians agree that it is important to consider the impact of cultural variables upon the assessment of multicultural groups, a crucial question would be Why such variables are not currently emphasized by clinicians in their clinical practices? At least two answers may be proposed (Paniagua, 1998). First, current standard clinical ratings such as the Minnesota Multiphasic Personality Inventory, the Child Behavior Checklist, the Zung Depression Scale, and the Schedule of Affective Disorders and Schizophrenia (Rut-ter, Tuma, & Lann, 1988) and diagnostic instruments such as the DSM-IV (1994) do not require an assessment of cultural variables that might lead to the identification of culture-bound syndromes (e.g., Table I) or disorders associated with specific cultural contexts (e.g., ADHD, Anorexia Nervosa, etc.). Thus, in clinical practice one would not be concerned with the fact that a given mental health practitioner does not include a screening of cultural variables when making a diagnosis of mental disorders with clients from the multicultural groups generally seen in mental health services (e.g., African American, American Indian, Asian, and Hispanic clients). (As noted above, the DSM-IV recommended culture-bound syndromes and specific cultural variants clinicians to be considered in the assessment of psychiatric disorders; practitioners, however, are not required to screen these syndromes or cultural variations when making a psychiatric diagnosis using the DSM-IV; clinicians are simply encouraged to consider that recommendation.)
Third, reimbursement for clinical activities involving the assessment of cultural variables is not a practice among major private insurance, Medicaid, and Medicare. In the case of culture-bound syndromes, for example, a practitioner cannot expect to receive payment for the assessment and treatment of susto, ghost sickness, mal puesto, koro, ataque de nervios, and other culture-bound syndromes listed in Table I. For this reason, a clinician in private practice would not be expected to spend time screening such syndromes in those cases when his or her efforts will not lead to reimbursement. (A distinction should be made between considering the assessment of culture-bound syndromes only in those cases when reimbursement for clinical assessment of such syndromes is available and the assessment of these syndromes because it is, indeed, important to assure that a culturally diverse client is experiencing a mental problem and not a given culture-bound syndrome. The first point is a matter of money; the second a matter of ethical standards leading to a recognition of cultural competence in the practice of a clinician involved in the assessment of multicultural groups; American Psychological Association, 1992.)
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