Cultural Bias 2.0

Cultural bias | Ethnocentrism | What are its definitions and implications?

• Ethnocentrism: Triandis (1990) defines it as the tendency to use one’s own ethnic or cultural group’s norms to decide what is “natural” and “correct” for everyone. This may be motivated by the belief that one’s own race, ethnic, or cultural group is the most important. Ethnocentrism can lead to incorrect assumptions about other people’s behavior, based only on one’s own norms and beliefs. • Cultural relativism takes the opposite stance. It values a culture’s practices from that culture’s own point of view, rather than judging them by outside assumptions.

Cultural bias | Cultural relativism | What is it and how can it reduce bias?

• Cultural relativism: Ethnocentrism may take obvious forms, in which one consciously believes that one's people's arts are the most beautiful, values the most virtuous, and beliefs the most truthful. • The principle is sometimes practiced to avoid cultural bias in research and to avoid judging another culture by the standards of one’s own culture. For this reason, cultural relativism has been considered an attempt to avoid ethnocentrism. • Standardized psychological tests and diagnostic manuals (such as the DSM-5) were often normed primarily on Western, individualistic populations. Cultural relativism helps clinicians recognize that what appears "pathological" or "deviant" in a Western framework may be a normal, adaptive response or spiritual expression within another cultural group. For example, hearing voices and seeing things in Te Ao Māaori could be considered a gift as opposed to pathological behaviour • Relativism strips away therapist bias, preventing practitioners from imposing their own moral, social, or familial norms (e.g., viewing collectivist family structures or arranged dynamics as inherently dysfunctional) • Acknowledging that a client’s worldview is valid fosters psychological safety, reducing premature drop-out rates and stigma-driven reluctance • Furthering the same logic, clinicians or researchers who have ethnocentric tendencies may risk pathologising societal norms from other cultures as deviant based upon the standards of their own. They risk viewing, for example, collectivised family structures as inherently a risk factor and dysfunctional, which may influence treatment

Cultural bias | Etic approach | What is it, and what are its risks and benefits?

• Etic Approach and Imposed Etics • Looks at behavior from the outside using a global or universal framework. It assumes core psychological processes (such as basic emotions or symptoms of major depression) apply to all human beings) • Similarly to the risks of ethnocentrism, using an etic approach could risk leading to an ethnocentric bias when studying cultures from the outside where Western-centric norms are misapplied to non-Western groups, thereby missing culture-specific expressions of distress or misdiagnosing norma behaviour as pathology, for example. • However, when applied appropriately, it can be useful for creating cross-cultural comparisons

Cultural bias | Emic approach | What is it, and what are its risks and benefits?

• Emic Approach • Examines behavior from the inside using the specific meanings, language, and categories of the local culture. • Clinicians focus on indigenous illness categories or culture-bound syndromes (e.g., somatic vs. psychologically-based expressions of distress where many cultures conceptualise psychological pain in terms of physical sensations such as Jhum-Jhum syndrome in Nepal: Tingling and numbness experienced as a physical manifestation of stress). • However this, makes cross-cultural comparison difficult and can limit generalisability of psychological processes and therapeutic treatments to specific cultural contexts

Cultural bias | WEIRD | What does it mean, and what is the sampling problem?

• W.E.I.R.D • Western, Educated, Industrialised, Rich, Democratic; these are markers of a large amount of studies which mean that not all studies can be applied universally. 12% of world population but between 80-96% of psychological research is based on said sample (as of 2010 according to Henrich)

Cultural bias | Solutions | How could research samples be improved?

• Expanding beyond WEIRD samples: use the statistics of WEIRD and also the Berry (1967) Independence and Conformity in Subsistence-level Societies to demonstrate why. Include non-western and developing populations and if possible investigate replications in other samples • Otherwise, caution against (2nd solution) making universal generalisations beyond the sample

Cultural bias | Solutions | How could diverse researchers and cultural input reduce bias?

• Diversify Research Staff: Similarly, reference differences in culture from Berry (1967) and also use that to argue how research constructions could be biased by experimenters assumptions. Also reference the Griner & Smith (2006) to argue that they could identify blind spots regarding language and non-verbal cues and social norms that may influence cross-cultural testing • Following on from this and using the same body of evidence, potentially have community-led recruitment with community leaders to also identify blind-spots • Use the Mahi a Atua (Rangihuna et al., 2019) study to argue how Maori values and concepts could be integrated into clinical practice or research designs. This promotes an Emic approach using indigenous psychologies to build theories. Could also extend this to validating assessment tools across cultures and as well have external input / more diverse research group

Cultural bias | Solutions | How should researchers and clinicians reflect on culture?

• Again, supported by Berry (1967) Independence and Conformity in Subsistence-Level Societies to argue for researchers actively reflecting on their own cultural values and privileges before and during a study • Discussions of culture in psychiatry tend to focus on the minority patient who is presumed to be culturally distinctive in some way. However, psychiatry itself is a cultural institution. Medical anthropology has shown how many aspects of psychiatric theory and practice are based on specific cultural concepts of the person. The perspective of clinicians is also a function of their own ethnocultural background, their professional training, and the context in which they work. Hence, it is best to frame issues of cultural difference not simply in terms of the characteristics of patients or communities, but in terms of differences in the perspectives of patient and clinician in what is always, to some degree, an intercultural encounter. • General clinician cultural competency • the clinician’s task involves acquiring sufficient understanding of the patients’ point of view and preferences to negotiate a diagnostic interpretation and treatment strategy that will be acceptable and effective. There is considerable evidence that conventional psychiatric approaches are not effective for many patients because of the failure to undertake or accomplish this clinical negotiation. One indication of this failure is the generally low rate of patient “compliance” with treatment where rates of noncompliance are much higher in intercultural settings

Cultural bias | Limitations | Why might ethnic matching not be sufficient or feasible?

OMG note this as a solution but then use this evidence to show the limitations

• It is worth noting, however, that the mere fact that a clinician and patient share some background (or a researcher on a team) may not guarantee culturally appropriate care because in the course of professional training some clinicians may distance themselves from or devalue the tacit cultural knowledge they once had.

• For many smaller migrant groups, and in settings of extreme cultural diversity, such ethnic matching is not feasible because clinicians with the requisite linguistic and cultural background are not available. In this context, it is essential for clinicians to develop generic cultural competence. The basis of any general ability to work with people from diverse cultural backgrounds begins with the clinician’s knowledge of their own ethnocultural identity and the implicit biases this brings

Berry (1967) | Purpose and context | Why was the study conducted, and why these societies?

• Shows something that was thought as fundamental as conformity is actually culturally influenced • Purpose: Barry, Child, and Bacon (1959) distinguished between low and high food-accumulating societies and suggested that to best meet their economic needs, in societies with low food accumulation (hunting or fishing peoples), "adults should tend to be individualistic, assertive and venturesome [p. 53]," while in societies with high food accumulation (pastoral or agricultural peoples), "adults should tend to be conscientious, compliant and conservative [p. 53]." • However, no psychological instrument to gauge actual independence or conformity has yet been employed to discover if these differing types of subsistence economies with their concomitant socialization practices do, in fact, tend to produce individuals with opposing tendencies to accept group norms​ • The Inuit world is void of edible vegetation; the people rely solely upon hunting and fishing for their livelihood and hence might be considered a good example of a low food-accumulating subsistence society… The Temne, on the other hand, are mostly rice farmers, harvesting a single crop each year which must then be meted out in daily units until the following harvest; they thus represent a high food-accumulating subsistence economy

Berry (1967) | Hypotheses | What did Berry predict?

• It was considered that in an Asch (1956) type task members of these two societies would tend to accept the suggestion of the group norm to different extents; the Temne (who might be characterized as "group-reliant") should exhibit greater conformity than the more self-reliant Inuit. • Secondly, it was considered that in the more traditional communities within each society, the suggestion of the group norm would be more effective than in those transitional, and generally less socially cohesive, areas.

Berry (1967) | Methodologies | Describe the samples and full conformity task.

• Two samples were drawn from each society, one composed of traditional people without western education and one composed of people in transition to western life. In addition, two samples of Scots, one rural and the other urban, were selected as a reference group. • Six test sheets, each with nine horizontal lines, were presented. A standard line was at the top and eight test lines of varying lengths were beneath it. On Sheet C, an X was placed beside Test Line 6 and the subject was told: Here is another sheet with nine lines on it, one here at the top, and eight beneath it. This time I am going to give you a hint. Most Temne (or Inuit, or Scottish) people say this line [experimenter pointed to number 6] is equal in length to the one at the top. Which one do you say? • In this case, the designated line was actually the correct one. On Sheets D, E, and F, the same instructions were given as for Sheet C, but in each case the designated line was five lines away from the correct one. Over these three sheets the discrimination was eased, with D having 1 millimeter difference between the lengths of successive lines, E, 2 millimeters, and F, 3 millimeters.

Berry (1967) | Results and discussion | What were the findings and conclusions?

• The differences between the Temne and Inuit means are both significant beyond the .01 level (2=13.72 for the traditional samples, and 8.69 for the transitional samples). However, none of the differences between samples within each culture (transitional vs traditional) reaches significance (t = 0.65 for the Temne, 0.93 for the Inuit, and 0.24 for the Scots). • Both traditional and transitional Temne samples show a highly significant tendency to accept the suggestion of the group norm, while the Inuit almost disregard it. • Although all three rural/traditional samples show a greater tendency to accept the suggestion of the group norm than their urban/transitional counterparts, none of these differences is significant. • It is apparent then, that the Temne and Inuit societies have been able to produce the degree of conformity required by their respective subsistence-level economies, and that for these two societies at least, the Barry et al. predictions have been confirmed by the application of a psychological measure. It thus may be concluded that low foodaccumulating societies do tend to produce individuals who are independent and self-reliant, while high food-accumulating societies tend to produce more dependent and group-reliant members. • This tendency, furthermore, is carried into the transitional period (where economic life is no longer at a subsistence level), thereby demonstrating the persistence of psychological and cultural patterns in the absence of their ecological origins

Griner & Smith (2006) | Purpose | Why investigate culturally adapted interventions?

• Purpose: In short, although psychologists may believe that it is beneficial to adapt mental health interventions to meet clients’ needs, they may also believe that there is currently little empirical justification (with rigorous evaluations of effectiveness) for doing so. As a result, they may do very little to modify their practices. • Why: Even with increasing acknowledgment of multicultural issues, contemporary psychotherapy continues to reflect the values of Western culture, most notably a persistent bias toward individualism. Collectivistic values and contextual circumstances are often ignored or minimized.

Griner & Smith (2006) | Recommendations | What four cultural adaptations were proposed?

• First, scholars emphasize the need to explicitly incorporate the cultural values of the client into therapy. Clients of color are more likely to seek out and use mental health services when their values and beliefs are congruent with the interventions provided • Second, to facilitate client perceptions of therapists’ understanding and similarity, clients can be matched with therapists of the same race/ ethnicity who speak the same native language (Coleman et al., 1995; Lam & Sue, 2001). Although there are confounding variables that need to be considered, research has shown that when compared to nonmatched clients, clients matched to therapists by native language and ethnicity are less likely to drop out prematurely from therapy and more likely to report satisfaction with the interventions provided (Campbell & Alexander, 2002; S. Sue, 1998). • Third, mental health interventions and systems should be easily accessible and targeted to clients’ circumstances (Flaskerud, 1986; Zane et al., 1994). Whenever possible, services should be delivered within the community where clients reside (Uba, 1982). Optimally, the mental health services should be specifically designed for the local context. For example, Asian American clients who attended clinics specifically designed for Asian Americans living in ethnic neighborhoods of Los Angeles had better outcomes than those who attended mainstream mental health clinics (Yeh, Takeuchi, & Sue, 1994) • Fourth, mental health practitioners should cooperate with support resources available within clients’ community, spiritual traditions, and extended family (e.g., Armengol, 1999; JacksonGilfort et al., 2001; Prizzia & Mokuah, 1991). For example, when Latina mothers were explicitly involved in the treatment of their children through recounting cultural folk stories, the children showed significant reductions in presenting symptoms compared to traditional therapy even after one year of follow-up

Griner & Smith (2006) | Results | What study designs, measures and adaptations were included?

• The majority (82%) of the 76 research studies included in this meta-analysis involved experimental or quasi-experimental research designs. However, 14 studies reported data from a single intervention group without comparing outcomes to a control group (e.g., pre to posttest differences). • The studies included in this meta-analysis involved several different types of outcome measures (i.e., mental health symptoms, client retention, client satisfaction) • The most frequently mentioned cultural adaptations (84% of all studies) involved explicitly including cultural values/concepts into the intervention. In addition, many of the interventions attempted to match clients to therapists of the same ethnic group (61%) and native language if other than English (74%). In at least 41% of the reports, the clinic or organization providing the mental health intervention explicitly served clients from culturally diverse backgrounds. Several studies also included explicit collaboration/consultation with individuals familiar with the clients’ culture (38%), outreach efforts to recruit underserved clients (29%), cultural sensitivity training for professional staff (17%)

Griner & Smith (2006) | Results | What was the overall effect size and how consistent was it?

• Across all 76 studies, the random effects weighted average effect size was d .45 (SE .04, p .0001), with a 95% confidence interval of d .36 to d .53. The data consisted of 72 nonzero effect sizes, of which 68 (94%) were positive and 4 (6%) were negative. Effect sizes ranged from d .48 to d 2.7.

Griner & Smith (2006) | Discussion 1 | How effective were adaptations relative to conventional therapy?

• The results of this meta-analysis demonstrated an overall positive effect of culturally adapted mental health interventions. Across all 76 studies the random effects weighted average effect size was d .45, and across 62 studies with experimental or quasi-experimental designs, it was d .40. • Given that previous psychotherapy outcome research has demonstrated very minimal differences (omg this was the Dodo bird study, so it’s saying that differences between traditional forms of psychotherapy), typically ranging from d 0 to d .21 (Wampold et al., 1997), across various forms of psychotherapy (e.g., cognitive vs. psychodynamic vs. humanistic) the results presented here are noteworthy. Overall, culturally adapted interventions resulted in significant client improvements across a variety of conditions and outcome measures • Bring the Wampold et al (1997) study in to say that therapeutic alliance is one of the cornerstones of effective psychotherapy and this facilitiates that

Griner & Smith (2006) | Discussion 2 | What did same-race groups and participant demographics suggest?

• Limitation/solution (so cultural adaptions should be targeted towards a single group of people): An important finding in the present metaanalysis concerned the racial composition of the participants. Interventions provided with groups of same-race participants (d .49) were four times more effective than interventions provided to groups consisting of mixed-race participants (d .12). This finding implies that cultural adaptations to mental health interventions may be more efficacious when the adaptations are specific to a particular racial/ethnic group. Multicultural adaptations designed to be sensitive to many cultural groups are still more efficacious than interventions without any cultural adaptations, but optimal benefit is apparently derived when the treatment is tailored to a specific cultural context • Additional information for target demographics: studies with participants of higher chronological age and with higher percentages of Hispanic/Latino(a) participants had effect sizes of greater magnitude • One possible explanation for these results relates to the acculturation level of the participants. Older populations tend to be less acculturated (and therefore possibly in greater need of cultural adaptations to psychotherapy) than younger populations, and Hispanic/Latino(a) populations are highly likely to speak Spanish, be migrants, and remain in lower socioeconomic status years after migration

Griner & Smith (2006) | Discussion 3 | What did matching by language and ethnicity show?

OMG use matching based on ethnocultural and linguistic backgrounds as a solution, and then go into the limitations associated with ethnocultural matching

• studies in which the client was matched with a therapist based on language (if other than English) had outcomes that were twice as effective as studies that did not. This finding strongly supports the need for therapeutic interventions to be conducted in clients’ preferred language.

• Limitation: Studies in which clients were not apparently matched to therapists based on ethnicity had average effect sizes that were higher than studies in which ethnic matching was generally attempted but not consistently conducted… the result found in our metaanalysis was in the opposite direction of that typically expected.

• This may be partly due to intracultural or intraethnic heterogeneity within participating populations. Simply being part of the same ethnic group may not indicate a common understanding

Griner & Smith (2006) | Discussion 4 | What could explain the beneficial effects?

• Explanations why solutions work: Contemporary psychotherapy outcome research highlights the salience of common factors, such as the level of client trust and the quality of the therapeutic relationship, much more than specific modifications to psychotherapy content or method of delivery (Wampold et al., 1997). Applying this line of reasoning to our findings, it is possible that the positive client outcomes associated with culturally adapted mental health interventions in this meta-analysis may be more related to clients’ increased sense of trust (and decreased concerns about institutional racism) than to the adaptations themselves.

Rangihuna et al. (2019) | Purpose and context | Why develop the model, and what cultural perspectives support it?

• Purpose: This model developed from a desire to implement Te Whare Tapa Wha within psychological practice with the primary aim being to provide a set of guidelines easily applied in clinical settings.

• Psychological practice is usefully guided by frameworks that can be applied to individual circumstances and that are inclusive of individual differences. However, assessment/intervention is not limited to the interaction between the clinician and the client. It is instead a combination of multiple relationships that occur within a larger system.

• (Durie 1985) A Maori Perspective of Health A characteristic of Western thinking is its analytical capacity. The whole is quickly dissected into its component parts so that greater understanding might occur. Individual properties are used to distinguish one object from another, one person from another. By contrast, Maori thinking could be described as holistic. Understanding occurs less by division into smaller and smaller parts, than by synthesis into a wider, contextual system. Consistent with this style of thinking, health is viewed as an inter-related phenomenon rather than an intrapersonal one.

• (Durie 1985) A Maori Perspective of Health Healthy thinking, in Maori terms, is integrative not analytical. The individual whose first thoughts are for himself, his personal ambitions or his own body is considered unhealthy, even though his body may be the epitome of fitness.

Rangihuna et al. (2019) | Methods | How was the model developed and piloted?

• Standard literature review, interviewed Māori and non-Māori health clinicians including psychologists, GPs, nurses, social workers. They were asked how they were implementing Te Whare Tapa Wha within their practice. • It became clear from these interviews that while these clinicians were familiar with the core principles they often struggled to put the model into practice within their clinical settings. • The developed model was then piloted by two psychologists, one nurse, and one GP over 5 years. Discussions between clinicians provided feedback for the Meihana Model in clinical settings

Rangihuna et al. (2019) | Implementation | What are the limitations and training considerations?

• To adequately implement the Mehiana Model requires adequate professional development and support provided to clinicians and researchers; however, this requires a large existing body of educators who are culturally competent and capable of communicating this knowledge, which we currently lack–could turn into solution with greater training

Meihana model | Whanau | Explain the definition, rationale and service implications.

• Definition: Client support networks. • Rationale: Whanau are seen as having a key role in the assessment, intervention and monitoring process of the client/whanau. • Relationship to Service: Policies are needed to support the engagement of client without isolating whanau (Ministry Of Health 2001; Durie 2001). This involves including whanau within the assessment and intervention processes, and having space that allows this within clinical settings. Whanau should have the opportunity to identify what level of integration of Mãori cultural input they want to engage in and to give feedback to services about their perceived level of cultural safety and competency. • (Durie 1985) A Maori Perspective of Health This family-oriented approach with its tendency to foster a group (rather than individual) identity [16] stands in contrast to the Western attitude to maturity and good health where an independent lifestyle is often equated with good mental health and where emphasis is given to self assertion, lack of dependence on parents and the elimination of the generation gap. To be a total person however, 'in one's own right' is, from a Maori perspective, to be in an unhealthy state. The individual has no validity of his own. While his personal talents may be considerable, an insistence on independence is regarded as immaturity, and an inability to depend on the family, is seen as unnecessarily defensive. It is in this area that many counselling and therapeutic approaches within the mental health field have little credibility in Maori eyes.

Meihana model | Tinana | Explain the definition and rationale.

• Definition: Working to promote physical well-being of client/whanau. • Rationale: To ensure that the service encompasses the importance of physical well-being and its relationship to overall psychological well-being.

Meihana model | Hinengaro | Explain the definition, rationale and service implications.

• Definition: Covers thoughts, feelings, the mind-body connection, and how you process information and express

• Rationale: To ensure cultural accountability of measures used to provide evidence that supports or challenges hypotheses around the presenting behaviours.

• Relationship to Service: All assessment tools and diagnosis processes need to be placed within the appropriate cultural context to ensure valid hypotheses are drawn and that potential interventions sit within appropriate cultural norms. Services may develop practice guidelines or supervision modules that highlight potential biases or barriers when working with Māori (Ogden, Cooper & Dudley, 2003).

Meihana model | Wairua | Explain the definition, rationale and service implications.

• Definition: Level of attachment to identity, values, faith, tradition, ancestors, etc.

• Rationale: To investigate factors that contribute to engagement and therefore the level of attachment the client/whanau feel to the service and the services being provided at a more general level.

• Relationship to Service: limitation: Traditionally neglected by clinicians who consider that they do not have competencies to work in this area, or see it is the role of others to investigate this realm. However within the Meihana model all dimensions need to be explored to ensure effective service delivery that is responsive to Māori beliefs, values and experiences. This requires explicit support and resources to enable workers to extend beyond the potentially limited focus of western paradigms.

• Solution: These is earthly/ grounding attachment in terms of another person(s), thing and/or a place that is seen by the client as someone, something or where they feel they belong and are supported by for example a parent or close friend, a soft blanket or toy (especially with children), a home in which they felt safe, a place where they feel at peace. In risk assessments the absence of such a connection may indicate a higher risk for self-harm behaviour.

Meihana model | Taiao | Explain the definition, rationale and service implications.

• Definition: The physical environment of the services.

• Relationship to Service: The lack of Mãori mediums (e.g. posters, signage) within the organisation or the visible lack of Mãori staff may not support client/whanau in engaging with the service. Services need to develop policies around the pro-active recruitment of Mãori staff/clinicians (Herbert 2002, Robertson, Haitana, Pitama & Huriwai 2006). Further refer to Whanu in inclusive service spaces

Meihana model | Iwi-Katoa | Explain the definition, rationale and service implications.

• Definition: Societal structures that impact on the capacity of the organisation to work alongside client/ whanau.

• Relationship to Service: This dimension challenges the clinician to be reflective that their own social reality may be quite different from that of Mãori client/whanau and how that might constrain effective delivery of processes and protocols within the service (Harris, Tobias, Jefferys, Waldegrave, Karlsen & Nazroo, 2006). Iwi Katoa encourages services to look at the impact that service policies, processes and culture have on retaining and providing appropriate services to Mãori clients/whanau (Ministry of' Health 2002).

Schwartz et al. (2019) | Aims | What were the research questions?

• The study aimed to replicate previous findings indicating African Americans received a diagnosis pertaining to schizophrenia-spectrum disorders at a higher rate compared with White individuals and to examine whether they exhibited more severe disorganisation in speech as rated by clinicians. They further aimed to examine whether there were objective differences between groups in terms of disorganised symptoms and to determine whether such objective measurements of pathology moderated the relationship between race and clinician symptom rating and/or diagnosis. This last aim evaluated whether clinicians may be subtly influenced by linguistic style variations that may lead to a diagnosis of schizophrenia and/or related symptoms in African Americans but not in White individuals.

Schwartz et al. (2019) | Methodologies | How were participants and symptoms assessed?

• 251 participants; 75% had some form of schizophrenia-spectrum disorders while 25% had affective disorders

• Research assistants engaged the subject in recorded semistructured conversations about daily activities, hobbies, and interests.

• The Brief Psychiatric Rating Scale was used to characterize psychiatric symptoms. BPRS ratings were based on information obtained from medical records, the patients’ treatment teams, self-report, and behavioral observations made during the research interview

Schwartz et al. (2019) | Results | What diagnostic and speech differences were found?

• Approximately 83% of African Americans were given a diagnosis of Schizophrenia, compared with 63% of White individuals, and only 14% of African Americans were diagnosed with an affective disorder compared with 33% of White individuals. This difference was statistically significant. There were no statistically significant differences between African Americans and White individuals on clinician-rated BPRS scores

The study found significant disparities in diagnoses between African Americans and White individuals, with higher schizophrenia rates for African Americans and greater communication disturbances in their speech, leading to increased disorganization ratings by clinicians.

• In regards to the second aim, there were statistically significant differences between African Americans and White individuals on the total CDI score, t(237) 2.94, p .004, suggesting that African Americans showed more communication disturbance in their speech compared with their White counterparts. (objective measurement)

Schwartz et al. (2019) found that clinicians appeared to interpret certain speech patterns differently depending on a patient’s race. For example, African American patients were rated as more disorganized when their speech had less emphasis, whereas this pattern was not observed among White patients. The researchers also found that the relationship between speech characteristics, such as disorganization and changes in vocal pitch, and schizophrenia diagnoses differed between racial groups.

Race was the strongest predictor of diagnosis in both analyses. African American patients were 3.7 times more likely to receive a schizophrenia diagnosis in the analysis of speech disorganization and 2.9 times more likely in the analysis of vocal pitch. These findings suggest that racial differences in how clinicians interpret patients’ speech may contribute to disparities in schizophrenia diagnoses. However, the study does not prove that racial bias caused these differences or that African American patients were more likely to have schizophrenia.

Schwartz et al. (2019) | Discussion 1 | How can diagnosis and symptom ratings diverge?

• It is worth noting that symptoms, particularly those involving negative and disorganized symptoms, are typically based on behavioral observations. Hence, they reflect a relatively narrow observational time and information frame. Diagnoses, on the other hand, reflect a global, overall impression, that includes multiple streams of information including behavioral observation but also historical information and collateral report. omg this is because they only based their decision more or less on the observation of behaviour and thus if there were no statistically significant objective measurements of behaviour… then must ethnicity / cultural insensitivity to linguistic vernacular

• Given that diagnosis and symptom ratings are inherently subjective and often inappropriately reflect overall, global impressions rather than an isolated channel of behavior (e.g., such as speech; Alpert, Shaw, Pouget, & Lim, 2002), it seems plausible that cultural insensitivity plays an important role in diagnostic biases. However, perhaps a fast and efficient diagnostic decision does not allow clinician’s to fully process normative cultural variations. This is an important issue, as the use of cultural sensitivity training could likely reduce this sort of bias

• cultural insensitivity, which may be defined as “Assigning a mental disorder diagnosis primarily influenced by personal perceptions of or stereotypes about consumers’ ethnicity or culture risks inadvertently harming consumers psychologically or socially through misdiagnosis”. Clinicians may fail to take into account true racial differences or use inappropriate norming or reference populations when evaluating patient signs and symptoms. That is, clinicians may misinterpret culturally normal behavior from patients as being pathological when they are unfamiliar with them. Indeed, the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM–5; American Psychiatric Association, 2013) cautions that disorganized speech, for example, may be difficult to assess because of linguistic style variations across people and suggests that clinicians be particularly sensitive to varying styles of emotional expression, eye contact, and body language

Schwartz et al. (2019) | Discussion 2 | What were the language findings and their interpretation?

• First, we replicated previous literature suggesting diagnostic differences between racial groups. We failed to find group differences in current symptomatology. • Additionally, regarding the behaviorally based measure of disorganization (CDI), African Americans were observed to have a higher rate of ambiguous word meanings, wrong word references, and grammatical unclarities. This difference was observed in a significant interaction between CDI and race, which suggested that higher levels of disorganization were more likely to lead to a schizophrenia-spectrum diagnosis, but only for African Americans. • …highlighted the differences between what is commonly referred to as African American Vernacular English and African American English, compared with European American vernaculars, which highlights the idea that individuals use language differently • In summary, it is unclear whether the observed CDI differences in the present study reflect normative variations observed in the sociolinguistic literature more generally.

Schwartz et al. (2019) | Discussion 3 | What does the evidence suggest about cultural insensitivity?

• Objectively defined abnormalities in language and intonation were associated with increased rates of a schizophrenia-spectrum diagnosis in African Americans, but not increases in clinically rated disorganization or negative symptoms. Superficially, these data support the “cultural insensitivity” hypothesis of this study. • We proposed that cultural insensitivity may play a role when clinicians fail to take into account true racial differences or use inappropriate norming or reference populations when evaluating patient signs and symptoms, though further research is needed to properly evaluate this.