1. DISCUSS CULTURAL AND ETHICAL & GENDER CONSIDERATIONS IN DIAGNOSIS (FOR EXAMPLE, CULTURAL VARIATION, STIGMATIZATION)

2. CULTURAL CONSIDERATIONS

3. Culture bound syndrome – abnormalities and disorders are thought to be culture-specific Contrary to popular beliefs that disorders may appear to be universal (present in all cultures) Reporting Bias – Data is generally based on hospital admission which may not reflect true prevalence rates for particular ethnic groups or disorders. Culture Blindness – Culture blindness is the problem of identifying symptoms of a psychological disorder if they are not the norm in the clinician’s own culture Clinician is blind to other culture (blind to the patient’s culture)

4. CULTURE BOUND SYNDROMES - EXAMPLES EXAMPLE 1: SHENJING SHUAIRUO - (NEURASTHENIA) a culture bound syndrome that accounts for more than half of psychiatric patients in China. It is listed in Chinese classification system but not DSM-4. Symptoms listed are similar to mood and anxiety disorder combination. Example 2: Depression and diagnosis - It is common in western culture, but appears to be absent in Asian cultures. Asian societies are collectivist and they have lots of social support. Asian doctors say diagnosing depression is just as common among Asians but they visit doctors about physical issues, not emotional ones (Rack, 1982). Do not believe that it's the doctors responsibility, but family's Seek help for physical symptoms but don't mention mood

5. ‘CRAZY LIKE US’ – ETHAN WATTERS In his book Crazy Like Us Ethan Watters assesses the US’s global influence on mental disorder diagnosis and treatment and how a westernization of psychiatry is eliminating cultural differences. 1 – Introduction of Anorexia – Hong Kong 2 – Post-tsunami – Sri Lanka 3 – Shift in Schizophrenia – Zanzibar 4 – Marketing Depression – Japan

6. CRAZY LIKE US ANOREXIA - HK Death of Charlene Hsu Chi-Ying – publicity turned to western experts By 1997, fat phobia had become the single most important reason given for self- starvation Idea of anorexia was imported from western culture. TSUNAMI – SRI LANKA Most of the aid workers did not speak the local language or understand the culture. One example is that the aid workers felt that the locals needed to acknowledge that their family members were dead so that they could move on. They were also unable to make a distinction between the trauma caused as a reaction to the tsunami and the ongoing strains of the social and economic turmoil caused by that event. Idea of PTSD was imported from western culture.

7. CRAZY LIKE US SZ -ZANZIBAR Analyzed 3 families with members with Schizophrenia Because kept with families (Spiritual notion), members tended to do better. Western Culture could learn from this. DEPRESSION - JP The melancholic personality type was admired and aspired to. Sadness is seen as a way of tightening one's bonds with family and the community. One family sued work on accounts of karoshi (death by overwork) leading to suicide. Media connected mental illness (depression) as the cause of suicide. Prozac came up with a slogan that had cultural resonance, "depression is like a cold of the soul."

8. ETHICAL CONSIDERATIONS

9. What could be the effects of being labelled as having a mental disorder? Watch Video - Stigmatization

10. ETHICAL CONSIDERATIONS Confirmation Bias - when you pay attention to information that agrees with what you already believe and discount (ignore) information that contradicts it.

11. CONFIRMATION BIAS TEMERLIN (1968 ) Showed clinical psychologists, and clinical psychology graduate students a videotape in which an actor portrayed an ordinary, mentally healthy mathematician who had read a book about psychotherapy and wanted to discuss it with a psychologist. Before watching the tape, clinicians were informed by a prestigious psychiatrist that the individual on the tape was “a very interesting man because he looked neurotic, but actually was quite psychotic.” After viewing the tape, participants selected their best-guess diagnosis from a list of 30 choices: 10 psychotic disorders, 10 neurotic disorders, and 10 miscellaneous personality types, including “normal or healthy personality.” RESULTS A majority (60%) of the psychiatrists, along with 28% of the clinical psychologists and 11% of the graduate students, diagnosed the individual as psychotic. In contrast, none of the 78 participants in four control groups diagnosed this individual as psychotic. PRESTIGE EFFECT when a patient has already been diagnosed by someone respected in the field and a doctor confirms the diagnosis based on limited information. PRESTIGE EFFECT when a patient has already been diagnosed by someone respected in the field and a doctor confirms the diagnosis based on limited information.

12. CONFIRMATION BIAS MENDEL ET AL (2011 ) METHOD Researchers gave a case study to 75 psychiatrists and 75 fourth-year medical students. Participants were asked to choose a preliminary diagnosis of depression or Alzheimer disease and to recommend a treatment. The vignette was designed so that depression would seem the most appropriate diagnosis. Participants could then opt to view up to 12 pieces of further information. RESULTS For the preliminary diagnosis, 97% of psychiatrists and 95% of students chose depression. After looking at the further information, 59% of psychiatrists and 64% of students reached the correct diagnosis of Alzheimer disease. Psychiatrists who did not use information effectively to diagnose and only looked at information that confirmed their original diagnosis were less experienced. Participants were more likely to make the wrong final diagnosis if they chose to view six or fewer pieces of additional information. Confirmation Bias CHALLENGE The situations in which confirmation bias is tested is not naturalistic. The situations are abstract and lack any personal contact with the person that they are being asked to diagnose. This does not represent what happens in true diagnosis. Confirmation Bias CHALLENGE The situations in which confirmation bias is tested is not naturalistic. The situations are abstract and lack any personal contact with the person that they are being asked to diagnose. This does not represent what happens in true diagnosis.

13. ETHICAL CONSIDERATIONS Labeling Theory - Scheff's (1966) argues that if a person is diagnosed based on symptoms of "deviant behavior," society's reactions to this label will produce additional pathology or behavioral disturbance that causes mental illness or makes it worse. Stigmatization: Extension of to Labeling theory, has argued that labeling leads to the stigmatization - that is, the social rejection - of people with mental illness. Self fulfilling prophecy - Scheff (1966) argued that people may internalize the role of “mentally ill patient” and their symptoms could increase.

14. LABELING THEORY LANGER AND ABELSON (1974 ) Psychiatrists watched a video of a younger man talking to an older man with the sound removed. Half the therapists were told that the younger man was a patient; the other half, that he was a job applicant. After viewing the video, participants responded to a series of questions about the interviewee. RESULTS If the viewers were told that he was a job applicant, he was described as attractive and confident; if they were told that he was a patient, he was described as defensive, aggressive and/or frightened.

15. LABELING THEORY Gove & Fain (1973) carried out extensive interviews with 429 former mental patients. The vast majority stated that diagnosis had led to an improvement in their social relationships. Gibbons & Kassin (1982) found that labels actually lead to more acceptance of behavior. They found that when children were labeled with disabilities, they were blamed and punished less than non-labeled children for the same negative behaviors. Doherty (1975) found that people who rejected the mental illness label tend to improve more quickly than those who accept it! Link et al (1987) argues that a diagnosis may lead to social withdrawal by an individual because they fear social rejection. AGAINST Is there evidence that the mentally ill suffer from social rejection, stigmatization and discrimination? Labeling Theory CHALLENGE The greatest challenge to labeling theory is that psychologists are unable to empirically demonstrate that social rejection is the result of the diagnostic label rather than the behavior of the individual. Labeling Theory CHALLENGE The greatest challenge to labeling theory is that psychologists are unable to empirically demonstrate that social rejection is the result of the diagnostic label rather than the behavior of the individual.

16. GENDER CONSIDERATIONS

17. GENDER The double standard The LOA breakdown – Based on our previous information in each of the three Levels, discuss what is different about men and women (biologically, cognitively, socioculturally) What factors are different and influence their lives differently. What reactions are different and influence their lives differently. How might this impact diagnosis Discussion: Why are more men diagnosed as abusing alcohol than women? More on gender later when we examine Affective, Anxiety and Eating disorders in specific.

18. RECOMMENDATIONS??? What can and should psychologists do to avoid cultural, ethical and gender issues in relation to diagnosis?