Addressing Sociocultural Identities in Treatment

Melanie Hom, PhD, contributed to this post. Dr. Hom is a clinical assistant professor in the Department of Psychiatry & Behavioral Sciences at the Stanford University School of Medicine.

Sociocultural identities, such as sexual identity, race, or gender, impact how people view themselves and how others perceive them in society. Not surprisingly, sociocultural identities also influence the presentation of mental health symptoms and help-seeking behaviors (Clauss-Ehlers et al., 2019). Best clinical practice incorporates a person’s intersecting identities into case conceptualization and treatment planning.

However, many clinicians in large, fast-paced settings find it difficult to comprehensively and efficiently assess sociocultural identities and their potential impact on mental health. Interviews can be time-consuming and are not always feasible—for instance, in some hospital or primary care settings, where clinicians have limited time with their patients. Clinicians and researchers have traditionally used fixed-response multiple-choice self-report questions (e.g., with lists of checkboxes) because they are quick to answer, interpret, and aggregate across patients. Given these benefits, such checkbox forms are often the only option offered for capturing identity information into electronic medical records.

While checkboxes are efficient, they are problematic because many sociocultural identities do not fit neatly into a handful of boxes and because many identities occur on a spectrum. Some demographic forms attempt to address this challenge by including an “other” response option for people to write in their own response. However, having to consistently put oneself in an “other” category can contribute to people feeling excluded and marginalized (Wadsworth & Hayes-Skelton, 2015). In contrast, open-ended questions allow people to use their own words to describe their identities.

The Identities in Treatment Scale

This month, my colleagues and I at McLean Hospital published a paper in The Behavior Therapist describing the development of the Identities in Treatment Scale (ITS), a self-report survey that uses open-ended questions to ask about sociocultural identities and perceptions of how these identities contribute to daily stress and/or influence treatment goals. We developed the ITS for use in our adult partial hospital program because our clinicians desired a standardized way to capture richer information about sociocultural identities program-wide—information that was not being collected from the typical fixed-response demographic survey patients complete at admission.

The ITS is based on the adapted ADDRESSING framework (Hays, 2016). For each sociocultural identity, the survey asks the patient

1. How do you identify?

2. Does this identity contribute to your daily stress or to problems you’re hoping to address in this program?

We believe the second question is crucial because one cannot assume that a particular identity is important to the person or treatment.

Specifically, the ITS asks about the following identities:

• Age and generational influences
• Disability status
• Diagnostic status
• Religion and spirituality
• Ethnicity and race
• Sexual orientation
• Socioeconomic status
• Indigenous heritage
• National origin and current national status
• Gender identity

We also included additional identity-related factors relevant to mental health (e.g., relationship roles, career interests/passions).

After approximately 500 patients completed the ITS, we surveyed clinicians (psychologists, social workers, psychiatrists) for their feedback about its usefulness. On a Likert-type scale, clinicians reported that the ITS (1) helped them understand their patients’ identities, (2) facilitated a good assessment of identity factors relevant to clinical care, (3) facilitated treatment planning, (4) would be recommended by them for use by other mental health providers, and (5) was useful overall. In their written feedback, clinicians noted that the ITS provided comprehensive and nuanced identity-related information that was not captured elsewhere and/or that they had not had time to probe in detail during their intake sessions. Clinicians were often surprised by relevant information obtained even for patients who identify with a majority or dominant group (e.g., white male).

Main Take-Aways

• While it is critical to understand a client’s sociocultural identities and how they view these identities’ influence on mental health and well-being, this information can be difficult to efficiently assess in fast-paced treatment settings.
• While checkbox questions are efficient, open-ended survey questions allow providers to learn the words a patient uses to describe themselves and obtain richer information.
• In a partial hospital setting, clinicians valued the nuanced and comprehensive information about their patients’ sociocultural identities obtained via an open-ended survey. Our experiences administering the ITS in a partial hospital program suggest that such a survey

1. Is acceptable to both patients and providers,
2. Can be feasibly implemented in a short-term acute psychiatric treatment setting with adults with a range of presenting problems, and
3. Is considered clinically useful by providers.

• The follow-up probe asking about how an identity influences stress often revealed information that cannot be captured in standard demographic forms, such as barriers to treatment engagement and experiences of stigma.
• Future versions of the ITS should ask how a person’s sociocultural identities serve as a source of support, strength, and/or pride.