From [[Book - Psychopathology Foundations for a Contemporary Understanding]] # The Role of Gender, Race, and Class in Psychopathology by Barbara A. Winstead and Janis Sanchez-Hucles - Diagnosis, treatments have to take into considerations of heterogeneity of patient population - But the majority of descriptions of disorders, treatments, and research speak of clients and clinicians without reference to their social identities and with the assumption that diagnoses, treatments, and research outcomes can be generally applied to one and all. (1) Do gender, race, and class affect which psychological disorders individuals experience or how they experience them? (2) Are individuals from different groups treated differently by the mental health system? (3) Do recommended treatments work equally well for individuals from these different groups? (4) Should treatments take the demographic characteristics of the client into account? (5) Do the gender or race of the therapist matter? (6) What difference do gender, race, and class make? (7) And, if they make a difference, why? Terminology: - Race is outdated. Use Ethnicity or Culture instead. - Gender: Sex is the biological differences, while "gender" is the psychological and sociological differences. ## The role of Gender, Race, and Class in Diagnosis - Psychiatry diagnosis is often less than perfect because there is not accurate diagnostic tests to identify abnormalities. - To understand and treat a psychological disorder requires accurate diagnosis. The process of diagnosis and treatment is less than perfect, but the goal can be clearly stated: We wish to identify the problem, treat it, and thereby permit the client to lead a more productive and rewarding life. But how do we identify the problem? With physical symptoms physicians are aided by diagnostic tests that identify abnormalities in biochemistry, histology, or anatomy that signal specific disease processes. With psychological problems there are rarely physical signs such as an abnormal cell count. We may use diagnostic tests, but these are likely to be based on the self-reports of clients, not blood chemistry or cell cultures. Often psychological diagnosis is accomplished through interviews, in which clinicians learn about symptoms directly from the client, through psychological tests or through observations of symptoms. There are class differences to diagnosis. Prevalence rates of disorders. - In DSM-IV-TR Social class is referenced: - as a link to etiological factors for mental retardation, such as lead poisoning and premature birth, and as a context for understanding undesirable behaviors, such as carrying a weapon or joining a gang, that might be considered indicators of conduct or antisocial disorder but could, in an impoverished or high crime neighborhood, be self-protective. - also states that undifferentiated somatization disorder is more common in women of lower SES and that conversion disorders are more common among lower SES and rural individuals [[202209140829 Symptoms can be presented differently in different culture. Like my mother complain of wind pain in her legs as compared to tingling or pulling of nerve]] - #alcohol Specific ethnic differences are presented for alcohol-related disorders: lower in Japanese, Chinese, and Korean populations, equal in whites and African Americans, higher in male Hispanics but lower among female Hispanics. Alcohol abuse is also related to lower education, unemployment, and lower SES, although abuse of alcohol may well have contributed to these variables rather than being an outcome of them. - [[psychosomatic]] #somatization Although somatization disorder is relatively rare in men, it occurs at a higher rate in Greek and Puerto Rican men. Finally DSM-IV-TR takes note of the research (see below) revealing that African Americans are more often diagnosed with schizophrenia, also noting that whether this is a true difference or the result of bias is unclear. Ethnic differences in bipolar disorder have not been found. Bulimia nervosa is described as “primarily white” (p. 592). #bipolar_disorder ## Gender, Race and Class Bias - Gender and Race may cause bias in diagnosis - 1997, Garb summarised research literature on gender, race and social class bias in clinical judgement. He concluded that race bias for diagnosis of schizophrenia and psychotic affective disorders such that black and hispanic patients were more likely than white patients to be misdiagnosed with schizophrenia when symptoms suggest psychotic affective disorders and gender bias such that a diagnosis of antisocial personality disorder (APD) is more likely to occur for males and histrionic personality disorder (HPD) for females. Widiger (1998) delineated 6 ways that diagnosis may reflect bias 1. Biased diagnostic constructs 2. Biased diagnostic thresholds 3. Biased application of the diagnostic criteria 4. Biased sampling of persons with disorder 1. Who are the people who come for treatment willingly or by force? What about those who did not come for treatment? (page 51) 5. Biased instruments of assessment 6. Biased diagnostic criteria 1. How to tests were developed? whether they are representative. (page 45-46). Are there biases against gender, age? Critics of DSM argued that any classification system of psychological disorder represents an ethnocentric construction (You use your own standard to judge another person). Biased Diagnostic Standards Critics of DSM have argued that any classification system of psycho- logical disorder represents an ethnocentric construction of what an idealized, or nonpathological, self is. Gaines (1992) suggested that the essential feature of DSM diagnoses is absence of self-control, a Western/European ideal. Others argued that the diagnostic constructs were sexist and that women are pathologized by DSM diagnostic criteria (Brown, 1992; Caplan, 1991, 1995; Kaplan, 1983; Walker, 1994). HPD and dependent personality disorder (DPD) have been cited as the most egregious examples of gendered, in this case feminine, traits being used to establish the presence of psychopathology (Kap- lan, 1983). Kaplan (1983) proposed “independent personality disorder” and “restricted personality disorder” and Pantony and Caplan (1991) suggested “delusional dominating personality disorder” as comparable, but masculine stereotyped, disorders. Others, however, argued that DSM-III already included personality disorders that captured maladaptive masculine traits, specifically, APD and compulsive personality disorder (Williams & Spitzer, 1983). [[202209140927 Same underlying condition may present differently in men and women]] Diagnostic Criterion Bias. Differences in gender may cause presentation of problem differently. For example, heart attacks present differently for women and men. - Perhaps men and women present stresses, emotional issues differently too! In the case of heart attacks, although the underlying condition is the same, the presenting symptoms for women and men are somewhat different. It is likely that for some psychological disorders a similar process occurs. ## Influence of the client on therapy outcomes Higher SES tend to stay longer in psychotherapy. - Wierzbicki and Pekarik (1993), in a meta-analysis of psychotherapy drop out, found that race (minority status), low level of education, and low SES all significantly predicted dropping out of therapy. Reis and Brown (1999), in their review of three decades of research on the unilateral terminator (i.e., a “client who terminates treatment before the clinician believes the client is ready,” p. 123), conclude that SES is a reliable predictor of unilateral termination and that despite some nonsignificant results, nonwhite clients are also more likely to terminate unilaterally. In a study of individual therapy in a substance abuse clinic, researchers found that being female and African American were independent predictors of early treatment drop out (King & Canada, 2004). - ==Thinking, who are the patients who will be more keen to use HOPE, or follow up with treatment? And success rates should also consider the heterogeneity of participants, not just by diagnosis== ## Client-Therapist Matching [[psychotherapy]] #therapist #therapeutic-relationship