Whodas 2.5: Cultural Case Formulation

In 2013 the Diagnostic and Statistical Manual 5, the DSM 5, was published by the American Psychological Association which expanded upon, added, or changed diagnostic criteria. Changes to the DSM 5 include completing a Cultural Case Formulation with a semi- structured interview that takes into account each clients unique cultural traits and influences.
Several all over changes include using the World Health Organization Disability Assessment Schedule, the WHODAS 2.0, that is used to screen clients for their current level of physical functioning, social life participation, and cognitive functions. Using the WHODAS 2.0 allows clinicians to have more concrete levels of functioning rather than using a broader measure such as the Global Assessment

of Function, the GAF. The GAF serves as a subjective measure of a clients function and the scoring is left up to the individual clinician's impression. The GAF has been criticized for being outdated and subject to manipulation as a person may need a certain score to justify being in a program. The client does not have input in what the GAF score is where as the WHODAS is derived solely from client input leading it to be more accurate. The Global Assessment of Function has been removed from the DSM 5 in favor of the WHODAS 2.0. Evidence based practices are also preferred in the DSM 5 and the new criteria allow more accurate diagnosis to be made (American Psychological Association, 2013, Klott, J. 2013, & "Frequently Asked," 2013).
Several other changes to the DMS 5 include the revision of the diagnosis of the Autism Spectrum Disorder which removed the diagnosis of Asperser's disorder. The Substance abuse related diagnosis have been updated and now include the severity index of mild, moderate, or severe. The diagnosis of mentally retarded has been changed to intellectual disability, and communication disorders have also been updated. Criteria for Schizophrenia have been added as well as for clients with a schizoaffective disorder (American Psychological Association, 2013).
Perhaps of the most important updates is in the field of trauma. Clinicians are able to diagnose Acute Stress disorder for trauma that occurred within the first four weeks of symptoms before moving to a diagnosis of Post Traumatic Stress Disorder. Jack Klott has discussed that the emphasis is now on treating Acute Stress Disorder with exposure therapy thus hopefully enabling clients to be able to process their traumas. Clinicians are able to now include the diagnosis of trauma in the development of childhood traumas that may be affecting adult clients in the present (American Psychological Association, 2013, Klott, J. 2013).
The role of initial assessment has also changed in the DSM 5.

A general checklist is included for clients to initially use and then cross cutting measures are used to provide information about specific client symptoms. The cross cutting measures allow the clinician to have data that can be used for diagnosis. These checklists are disorder specific and include severity levels that can be used in treatment planning and safety check lists. These can also be administered at intervals to track client progress over time. These can be used as part of an Evidence Based Practice model and can provide statistical data on clinician effectiveness (American Psychological Association, 2013).
During the initial interview with the client a new format is used called the Cultural Case Formulation. This takes into account the cultural identity of the person, their cultural definitions of distress, and cultural stressors. Psychosocial stressors are included which can be unique to each culture and the level that a person identifies with their culture can be taken into account when treatment planning. By assessing a client's cultural identity this may allow the clinician to identify barriers or commonalities between themselves and the

client.
Cultural concepts of distress can also be defined during the interview as well as cultural preferences for treatments or modalities. A Native American client may wish to include their shaman or medicine person in the treatment. A person may wish to use herbal medication instead of traditional psychopharmacological drugs. A persons idioms may also be explained. They may have "back pain" when instead a person really has severe depression. It may be culturally unacceptable to have a mental diagnosis but it may be more acceptable to have "back pain." Relationships within the culture can also be discussed, where the power resides within their family could be very important as a tool to recovery. If they are not used to having power, they may need assertiveness training if appropriate.
Incorporating these new diagnostic approaches can help the clinician gain a more complete picture of the person. The person is asked to define their view of the problem, provide their cultural perception of the cause, provide how their self coping skills are affecting them, and how their current coping skills are affecting their current desire for treatment. By asking the client their views of their issues, the client and clinician have a more even power base and are able to form a more collaborative approach.
My perception of how a client is behaving is not necessarily how the client view's their current problems. As Jack Klott states, a person in a state of resistance has not motivation to change since their current coping skills are "working" for them. Using the Cultural Case Formulation may allow a client to be able to identify their locus of pain or discrepancy more quickly thus allowing the treatment to be the clinician deciding what the problem is without client input (American Psychological Association, 2013, Klott, J. 2013).