Assesing Latinos For Depression
by: Kyle M. Kornbau LPC, NCC
Latinos often experience depression as physical aches and pains such as stomachaches, headaches, and backaches in addition to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (2000) diagnostic criteria for depression. Typically these somatic symptoms do not respond to medical treatment (Healthy Place Depression Community, 2003). There are unique and culture-related mental health symptoms and syndromes that interviewers should take into account when assessing minorities for mental disorders. An awareness of culture-bound syndromes and culture-related symptom presentation is crucial to an accurate interview and assessment (Lopez & Carrillo, 2001). However, an accurate assessment of depression in Latinos requires more than just knowledge of culture-specific symptom presentation. In fact, it is only one of many factors to consider when assessing a member of an ethnic minority group for mental disorders.
Another major factor to consider is cultural differences between the interviewer and client that affect the interaction of client and interviewer. Cultural etiquette is a major area in which an interviewer must be knowledgeable. An interviewer's ability to earn trust through appropriate behavior can ultimately determine the success of the assessment and continued treatment (Lopez & Carrillo, 2001). The ultimate challenge in assessing Latinos for mental illness is to use general information about the culture and apply it to the individual client without arriving at a stereotypical or oversimplified clinical impression (Lopez & Carrillo, 2001).
Based on a review of the literature, it is quite obvious that even though Latinos are now the largest minority group in the United States, there is not a standard method or procedure for interviewing and assessing Latinos for depression and other mental illnesses. However, some authors, including those of the DSM-IV have suggested guidelines and considerations for interviewing and assessing Latinos for mental disorders. Several pieces of literature in this area have offered suggestions on how to go about conducting a thorough interview and assessment that is minimally tainted by cultural factors. Most of these recommendations deal with cultural aspects that affect the clinician-client interaction and aspects that affect culture-specific presentation of symptoms, such as language, cultural identification, culture-bound syndromes and cultural explanations for behavior.
Rapport is a fundamental aspect of mental health assessment regardless of cultural differences (Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002). Without proper rapport and etiquette, it would be very difficult to even begin to gather appropriate and accurate information from the client. Santiago-Rivera et al. (2002) describe several aspects of human interaction that Latino cultures value. Some of the core Latino values that relate to rapport in a clinical setting are personalismo, respeto, dignidad, simpatia, confianza, and carino.
Personalismo refers to the idea that the person is the most important aspect of the situation. Personal warmth and genuineness are related to this value. There is an expectation that the client is more important than time frame or other factors affecting the session.
Respeto is closely correlated with the idea of respect. If the clinician is speaking Spanish, he or she should use the formal forms of "you" and also address the client with the proper titles. This may also need to be considered when matching client and clinician on age, and gender. For example, a middle-aged Latino man may find it disrespectful for a young woman to be asking him personal questions.
Dignidad (dignity) is simply the idea that the person has worth and is respected. This value is closely related to personalismo and respeto.
Latinos value the quality of Simpatia in people. A person who possesses simpatia is friendly, fun, and easy-going. Simpatia was described by Lopez & Carrillo, (2001) as "the avoidance of direct anger and confrontation between people so that relationships can flow smoothly and nicely" (P. 7). Simpatia could possibly interfere with a client being honest due to motivation to remain socially desirable. This should be held in mind when interviewing Latinos.
Confianza is the value of trust. Confianza is an important aspect of the therapeutic relationship. Latinos are not likely to disclose personal information unless they think the clinician es de confianza (can be trusted). However, once confianza has been established, Latinos may feel completely safe in disclosing personal information.
Carino "represents a demonstration of endearment in verbal and nonverbal communication" (Azara et al., 2002, p. 114). This involves using nicknames and adding endearing suffixes to names and occupations such as ito or ita, which when added to words denote a more intimate relationship. It is not recommend that the clinician use these terms, rather it is possible the client will opt to use them to refer to the clinician if he or she experiences a high level of rapport.
In addition to the above cultural values, Azara et al. (2002) makes 7 recommendations to help facilitate rapport:
1. Begin in a formal style, then move into more informal verbal and nonverbal interactions.
2. Address adults with formal titles: Mr. and Mrs.
3. Allow proximity in seating arrangements and personal communication.
4. Follow a hierarchical approach to greetings, starting with males or elders and adults before children.
5. Recognize differences in last names and possible differences in a client's recorded name. It is important to note that in Spanish-speaking countries, individuals keep both parents surnames, but in the United States, only the father's surname is typically used.
6. Maintain a flexible time frame without rushing the visit or conducting time-pressured sessions.
7. Start with platicar (personable small talk), a necessary prerequisite before engaging in serious conversation. (p. 115)
Once etiquette has been ensured, there are several considerations to be made regarding the interview and assessment. One of the most important considerations is language. Language can affect symptom presentation and if not treated properly can contribute to over or under pathologizing the client (Salazar & Valdez, 2000). If the client speaks more than one language, it is important to assess which language would provide the client with the best vehicle of expression. Henry (1997) as cited in Lopez & Carrillo (2001) has categorized Latinos into four categories based on language dominance. They are monolingual English speakers, English dominant bilinguals, Spanish dominant bilinguals, and monolingual Spanish speakers. Malgady and Costantino (1998) report a tendancy for symptom presentation to appear more severe when the client is interviewed in his or her native language. There is a tendency for symptoms to be inhibited when a Spanish-dominant bilingual uses English. Some have speculated that this is due to the added concentration required to speak the non-native language (Lopez & Carrillo, 2001). For some, English is primarily used outside of the home in work settings and to conduct business and is not used to converse or describe feelings. Due to the effects of using a non-native language on symptom presentation, Dana (1998) recommends using the client's first or native language.
If the clinician is not fluent in Spanish, the client should be referred to a clinician who is fluent in Spanish or an interpreter should be used. According to Lopez & Carrillo (2001), it is important to maintain eye contact with the patient and not the interpreter. It is also important to use non-verbal cues and be observant of the non-verbal cues of the client. Azara et al. (2002) recommends placing the interpreter behind the client to facilitate the therapeutic relationship between interviewer and client. Because of the cultural values of Latinos, young children or adolescents should never be used as interpreters in an interview. Family and friends should be avoided as interpreters because confidentiality cannot be guaranteed and a client is not likely to give full factual information. The interpreter may also filter what the client is saying (Lopez & Carrillo, 2001).
In addition to assessing which language is the most appropriate for the interview, the DSM-IV (2000) recommends assessing the cultural identity of the individual. This is defined by the amount of involvement the individual has with the culture of origin and the host culture. The client's level of acculturation should also be assessed. Acculturation is defined by Lopez & Carrillo (2001) as "the loss of traditional cultural attitudes, values, beliefs, customs, and behaviors and the acceptance of new cultural traits" (p. 41). In some cases, the effects of acculturation such as dysfunction and symptomology may require mental health services. Dana (1998) has identified four levels of acculturation. They are assimilated, bicultural, marginal, and traditional. There are instruments to measure acculturation such as the Acculturation Rating Scale for Mexican Americans-II and the Northern Plains Bicultural Immersion Scale. This information is used to assess the appropriateness of certain testing measures for Latino clients.
Only after language and cultural identity have been assessed, should symptoms be assessed. The DSM-IV (2000) communicates the importance of being aware of cultural explanations of the illness, culture-bound syndromes and typical symptom presentation for the culture.
Cultural explanations for mental illness are most commonly related to religious, spiritual or cultural superstitious beliefs. Some examples of this would be seeing visions and speaking in tongues (Kohl, 1998). In fact there is a danger of pathologizing any behavior that does not conform to American Ideals. Lopez & Carrillo (2001) offer some suggestions that may help clarify the difference between hyperreligiousness and a genuine mental disorder. First, ask if the religious preoccupation is a new or different behavior for the client. Next, ascertain whether it has increased or decreased in expression. Thirdly, ask if it is interfering with the patient's daily functioning. Also ask people who know the client if the behavior has become excessive. Finally, find out if the religious preoccupation endangered the patient's judgment or health.
When assessing depression in Latinos, it is necessary to be aware of culture-bound syndromes that are related to depression. Appendix I of the DSM-IV (2000) provides definitions of some culture-bound syndromes. For example, Nervios is a syndrome found in Latinos and is characterized by emotional distress, somatic disturbance, irritability, sleep problems, nervousness, tearfulness, and lack of concentration. Ataques de nervios is also a syndrome found in Latino cultures that could include mood disturbances. These are two similar culture-bound syndromes that can have overlapping symptoms with depression and that need to be considered when assessing Latinos for Depression.
Typical presentation of depression by Latinos is characterized by changes in mood. However, in addition, Latinos commonly experience Depression as bodily aches and pains such as back aches, stomachaches, and headaches, that do not respond to medical treatment (Kohl, 1998; Lopez & Carrillo, 2001; Healthy Place, 2003). Latinos experiencing depression may describe their condition as fatigue or nervousness (Healthy Place, 2003). Depression in Latinos appears to be related to physical health. This was evidenced by a study that found 26% of the sample to be depressed and only 5.5% of those depressed without physical health problems (Healthy Place, 2003). It may be difficult to distinguish between a diagnosis of Nervios and Depression. That is the reason it is so important to consider all cultural variables and even collect information from family members and friends. According to Kohl (1998), "extracting symptoms of depression or anxiety from a patient's description often cuts off the patient's full experience in order to fit a category" (p. 1).
Some authors have provided recommendations for interviewing Latinos to help facilitate collecting information. Santiago-Rivera et al. (2002) recommend avoiding the use of direct questioning which Latinos may find rude or insensitive. In fact, according to Lopez & Carrillo (2001), Latinos will usually answer 'no' when asked directly about the presence of mental illness in the family. A more successful method is to ask about symptoms or behaviors in a more indirect way to elicit factual responses. An additional technique for interviewing in a more indirect way is to ask to client to describe life experiences and along with those experiences, emotions and symptoms will surface (Santiago-Rivera, 2002). As stated earlier, maintaining ease in conversation (platicar) will facilitate the interview.
It should be noted here that the term Latino is used to refer to peoples who have a cultural heritage rooted in Spanish-speaking countries in Latin America, the Caribbean, Spain, Mexico and the Southwestern Untied States. Although, the information in this document is of a general nature, it is important to point out that the term Latino encompasses many peoples, any of which may differ from Latinos as a whole in some respects. Some of these peoples are Columbians, Cubans, Dominicans, Salvadorans, Mexicans, Nicaraguans, Peruvians, and Puerto Ricans.
There are several considerations to be made when assessing Latinos for depression. Many of these considerations have nothing to do with actual diagnosis of symptoms but rather the interaction with the client. In order to have a successful interaction, awareness of the Latino culture and values is important. Cultural and language assessments are absolutely necessary. It may be necessary to look for culture-bound syndromes and symptom presentation. Finally, assessing depression in Latinos may require the clinician to modify his or her interview techniques so they are in keeping with cultural values of Latinos.
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Kyle Kornbau is a Liscensed Professional Counselor and a National Certified Counselor that owns and is a therapist at Stonebridge Counseling. Kyle has a MA in psychology from North Carolina Central University. Stonebridge Counseling (http://www.SBcounseling.com) is a professional counseling practice located in Apex, NC and serves adults, Adolescents and children for various psychological issues. If you live in the greater Raleigh, Cary, Holly Springs area and are in search for a therapist, call Stonebridge Counseling at 919-434-6398 or e-mail info@SBcounseling.com
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