Friday, February 01, 2013

The Effects of Racial Bias on Diagnoses of Psychological Disorders by Christopher Bowers

The focus of my paper is racial bias in the diagnosis of psychological disorders. In the United States the majority of clinical psychologists are of European/Caucasian decent. This paper considers the possible consequence of Eurocentric clinica practices. Racial bias in this context can be seen specifically as an increased or decreased likelihood of a particular diagnosis based on the biological markers associated with the concept of race. The marker of skin color is of primary focus. For hundreds of years people have associated meaning and value with skin color.  This paper is an investigation of how clinicians in the field of psychology might misdiagnose a client based on the associations they have to the skin color of their client and/or their misunderstandings of cultural language and behavior.

The majority of the source material for this paper were studies that specifically addressed racial bias in the diagnoses of specific pathologies. In researching this phenomena it became evident that racial bias is most commonly present in the diagnosis of Axis I disorders such as schizophrenia, bipolar disorder and depressive disorders.  One study also looked at diagnostic racial bias in developmental disorders such as Oppositional Defiant Disorder and Attention-Deficit Hyperactive Disorder.  While the studies focus on Axis I disorders, we will see that racial bias may also affect Axis IV and V diagnosis.  Of the studies reviewed they were almost exclusively contrasting the diagnoses of European Americans and African-Americans.

These studies had as few as a hundred participants and as many as over 1500. The studies were conducted in several areas of the United States and most often included more than one county. The studies were set in state-supported mental health triage centers, other inpatient locations, as well as in outpatient programs. The evaluative tools most often employed were the DSM-IV itself or specific scales or tools from the DSM-IV. One study did use definitions from the International Classification of Disorders (Simpson et al., 2007).

The clinicians that made the actual diagnoses were most frequently psychiatrists or psychiatric nurses though one study used counseling professionals with either a Masters or Doctoral level of education. Only one study discussed the race of the clinicians and they were almost exclusively white, other than one clinician of mixed race (Schwartz, 2009).

This paper will also demonstrate that the abnormal psychology of an individual is affected by the social and institutional manifestations of racism. It is important to understand both how racial bias affects diagnosis as well as how racism affects the potential for various pathologies.

There are four themes that all the reviewed studies overtly or inadvertently address. These four themes will be the lens through which we view the effects of racial bias on diagnosing psychological disorders. The first theme is that of how normalcy is constructed and how that conversely defines social deviance. This will allow us to examine how culture can be mistaken as pathology. Second is the issue of cultural competency, the lack of which many believe to be the primary agent of racial bias in clinical settings. The third theme is that of language, significant in client’s description of symptoms. Lastly, we will look at the interplay of institutional racism within psychiatry and the institutional racism of the society in which psychiatry is practiced.

Definitions of Normalcy

If disorders are understood, in part, as a deviance of social norms, it is important to consider that these norms were likely defined and reinforced by the dominant group. There is historic evidence of treating cultural difference as a disorder, intentionally or otherwise (Ali, 2004). This is presumably what led to the development of culturally-bound symptoms in the more recent versions of the Diagnostic Statistical Manual (DSM). However, do these culturally-bound symptoms sufficiently mitigate racial bias? Attention-Deficit Hyperactive Disorder (ADHD) and Oppositional Defiant Disorder (ODD) provide examples of how definitions of normalcy could possibly result in pathologizing cultural norms. These disorders are not culturally bound and yet one study found that African American youth are more likely to be diagnosed with disorders such as ADHD and ODD (Schwartz & Feisthamel, 2009). The authors noted that these were disorders of deviance and the authors were concerned that certain cultural behaviors such as communication style were being seen as deviant by teachers and clinicians from the dominant group. The behavior of these youth might have also felt distressful or dangerous to members of the dominant group, even if no harm was intended.

These so-called “disorders of deviance” also serve as an example of how racial bias in diagnosing Axis I disorders may also affect Axis IV and V diagnosis. If a youth is punished for this deviance by being asked to leave the classroom or by being unnecessarily medicated this could lead to other life stressors or decreased academic and social functioning. This is speculative on my part and no studies suggested this to be the case. Never the less, these implications are troubling.

Another article discussed the intersection of gender and racial bias in the diagnostic process (Ali, 2004). For example, this author found evidence of sexist descriptors of women of color in the DSM casebook. If white women’s sexuality is viewed as the norm and other sexual values that are culturally specific are seen as a form of dysfunction, this would suggest that implicit in the field of psychology we find that different standards of normalcy are dependent on race.

It may be also that the sexualized descriptors are left over cultural assumptions from racist constructions of ethnic identity designed to marginalize and objectify women of color in colonial times. Colonialism offers us another perspective on racial bias in psychology. In considering the question of normalcy we can also look at the origins of psychiatry. Post-modern authors put psychiatric racial bias in the context of capitalism, empiricism, patriarchy, and other modernist ideologies (Fabrega, 2008). One of the blind spots of many modernist thinkers is their ignorance or negation of an implied colonial narrative. That is to say that in their observation, be it anthropological, pedagogical, or psychological, there is a sense of supremacy and domination in their evaluations and methods. Post-modernists suggest that western psychology is inherently racist since it is based on the same colonial narratives of other modernist assumptions and practices. As well, they would admonish us against culturally bias definitions of “mental illness” and even “empiricism” (Fabrega, 2008). A post-modern critique of western psychology will note that it is a field founded, developed and dominated by mostly white men. What has been considered normal in this field may only be normal for the people who dominate the field.

            Another study discusses the potential consequence of psychiatry being dominated by a ruling class. In addition to finding that youth of color were disproportionately diagnosed with ADHD and ODD, Schwartz & Feisthamel (2009) found that African Americans were more likely to be diagnosed with schizophrenia or other psychotic conditions than their white counterparts. Twenty-seven percent of the African Americans in the study were diagnosed with schizophrenia as compared with seventeen percent of the European Americans. Meanwhile, European Americans were more likely to be diagnosed with non-psychotic mood disorders. This suggests the potential that behavior that might be cultural and quite normal in a given culture, may be seen as threatening and diagnosable in the dominant culture. Put another way, when cultural behaviors deviate from a social norm create by the dominate culture, these behaviors are more likely to be seen as pathological.

            The authors maintain that these findings are consistent with prior research. They also suggest that part of the issue may be access. They suggest that suspicion of a mental health system dominated by the ruling class combined with a cultural stigma of mental illness may cause African Americans to be assessed at a later stage of the disorder, therefore having a higher rate of a positive diagnosis. Neighbors, Trierweiler, Ford, and Muroff (2003) further suggest that if this suspicion on the part of the African American client manifests as despondence it could be mistaken for a flat affect thus increasing the potential for a diagnosis of schizophrenia.

            There is specific evidence that the DSM-IV’s culturally-bound symptoms do not sufficiently mitigate racial bias. In a study of racial differences in DSM diagnosis using a semi-structured instrument, Neighbors, Trierweiler, Ford and Muroff (2003) found that African Americans were disproportionately over-diagnosed with more severe disorders, usually schizophrenia, and conversely, African Americans were disproportionately under-diagnosed with bi-polar disorder. If white people are more likely to get less psychotic diagnoses or black people more likely to get more psychotic diagnoses than this suggests a tendency towards “othering” people of color and reinforcing the normalcy of white people’s mental health. Furthermore, if the culturally-bound categories were designed to account for cultural differences between races, then how could this discrepancy occur? The authors found that separating subjective symptoms from cultural norms could be problematic:

            “Distinguishing hallucinations that indicate poor reality testing from culturally governed interpretations of subjective experience may be difficult” (Neighbors, Trierweiler, Ford and Muroff, 2003). This study came to the conclusion that using semi-structured instruments does not eliminate racial bias in part because while the DSM is ostensibly and objective tool, clinicians themselves are required to make subjective judgments about how to apply these objective criterion and this allows a loophole for unconscious predictive bias on the part of the clinician. One study exemplified this idea by suggesting that how clinicians connect their observations of symptoms to diagnostic constructs differed depending on if the client was African American or European American (Neighbors, Trierweiler, Ford, & Muroff, 2003).

Cultural Competency

 The post-modernist critique maintains that the same cultural insensitivity found in other modern, post-colonial disciplines such as anthropology and economics is also found in western psychological research and clinical application (Fabrega, 2008). Most studies suggest that cultural competency is the culprit of a biased or adulterated diagnosis. Issues of cultural competency suggest that the clinical interaction takes place in a historical and social context and that the interaction between clinician and client is not without the same prejudices that affect society at large. This is evident in the analysis of normalcy. While it is suggested that racial bias is a systematic and institutional problem, these biases are played out between individual clients and individual therapists. Therefore, the cultural competency of individual clinicians is a significant factor.

While the study of racial bias in the use of semi-structured instruments suggested that such instruments do not sufficiently mitigate bias the authors suggest also that clinicians competency in using such instruments is also important. If clinicians are trained on how to use sociocultural demographic information appropriately ethnocentric bias may be diminished (Neighbors, Trierweiler, Ford, & Muroff, 2003). The authors put particular emphasis on training clinicians to raise cultural alternatives to perceived symptoms. The authors of this study also suggest that symptoms of paranoia may actually be a learned response to racism, that clients may be suspicious of a clinician or institution based on past experience with racism. Part of cultural competency is to understand that social context in which clinical interactions take place.

Cultural competency also refers to the clinicians understanding of how symptoms may present themselves differently in various cultures. We will investigate this idea more in depth as we look at language. Schwartz & Feisthamel (2009) point out that symptoms of schizophrenia manifest differently for African Americans than European Americans. If a clinician doesn’t understand this, a misdiagnosis seems likely.  

            Several studies suggest the need for better cultural competency training and research. Schwartz & Feisthamel state that there is a perception in the psychiatric community that African Americans are more likely to have schizophrenia. Regardless of if this is accurate, the authors suggest that the very notion could predispose clinicians to demonstrating bias during diagnosis.


            A very important aspect to cultural competency is language. Language is the key to understanding how a client interprets their own condition. Particularly problematic is how to interpret self-reported information. This is important to the examination of racial bias due to the fact that how a client describes a symptom may be bound by local dialect or cultural stigmas and the meaning of either could be lost on an unskilled clinician.

Sometimes there may simply be a language barrier. Other times it may be a cultural barrier that manifests linguistically. Sometimes clinicians misinterpret culturally specific language as a pathological symptom. For example, studies on symptoms that had previously been described as a cultural syndrome called ataque de nervios (attack of the nerves) in mainly Latinas, was found to not be a “clinical entity” but instead a problem of functioning in relations to certain social circumstances (Halgin & Whitbourne, 2010). Similarly, Alisha Ali (2004) explains that women of color may be more likely to describe psychological ailments in physical terms, in part due to the potential of being stigmatized within their ethnic culture for having psychological problems.  For example, I have learned in my own work in the field of HIV that in some Latino families psychological manifestations of HIV are attributed to “el cancer” (the cancer) due to the stigma associated with HIV and it’s association with homosexuality in this culture.

One literature review on studies that compared rates of depression across different ethnicities found that family physicians and interns are less likely to recognize indicators of major depression in Latinos/Latinas and African Americans when using brief depression symptom questionnaires, and thus less likely to diagnose this population with depression (Simpson, Krishnan, Kunik and Ruiz, 2007). While there may be several reasons for this, the way that symptoms were described on the questionnaire may not have been culturally relevant and/or the clinicians did not recognize the answers given by these ethnicities as indicating depressive symptomology. How a question is worded, be it written or spoken, may affect the validity of the answer. If the question does not employ (or the clinician does not understand) the local “idioms of distress” the answer will be less likely to represent a valid response (Neighbors, Trierweiler, Ford, & Muroff, 2003).

One important aspect of cross-cultural language competency is that it applies not just to ethnic cultures but youth cultures, queer cultures, and class cultures. The more a clinician understands the slang of the cultures with which they work, the more effective and accurate a diagnosis can be made.

Psychiatric Implications of Institutional Racism

            Lastly,  it is important to consider the interplay of institutional racism within psychiatry with the institutional racism of the society in which psychiatry is practiced. Already apparent are several examples of racism within the practice of psychiatry: disproportionately higher diagnosis of more serious diagnosis in people of color, disproportionately higher diagnosis of less severe disorders in white clients, insufficient mitigation of bias in the DSM-IV’s culturally-bound categories, a field dominated by white practitioners, lack of cultural competency by white clinicians, and misunderstanding cultural descriptors of symptomology.

            The various explanations and suggestions offered make an attempt to explain the discrepancies as evidence of racial bias in diagnosis. However, there is one explanation which highly undermines this hypothesis and in doing so sets forth a startling hypothesis of its own. Looking at the possibility that higher rates of schizophrenia in African-Americans may not be attributed to a predictive bias, the authors consider the idea that perhaps the diagnosis rates are actually correct (Schwartz & Feisthamel, 2009). We are then left to consider if there is something about being African-American in the United States that contributes to higher rates of schizophrenia among that population. In other words, can racism be the cause of pathology? By in large the authors suggest that this is unlikely and that clinical bias is a more likely suspect of the discrepant prevalence. None the less, these alternative explanations are important to consider.             Some authors maintain that studies have shown that living in lower socioeconomic levels can cause or exacerbate schizophrenia and that the life stressors that poverty entails can contribute to triggering schizophrenia (Haglin &Whitebourne, 2010). In the United States, African Americans are more likely to be poor and to experience barriers to housing, employment, and health care.

What this would effectively mean is that due to institutional racism, simply being black acts as a genetic factor in a diathesis-stress model of dysfunction. This does not suggest that the genetics that make up racial markers carry within them a predisposition to mental illness, but that the environmental factors predispose individuals with certain genetic racial markers to schizophrenia. One author goes so far as to say that these diagnoses are a pathologizing of the traumatic response of people of color to oppression. Furthermore, in a society where people’s worth is associated with their ability to function in the dominant construction of normality, this phenomena is akin to blaming the victim (Ali, 2004).

            Other important issues that relate to psychiatry and institutional racism is the fact that African Americans are less likely to access preventative care, to receive psychiatric care prior to hospitalization, less likely to leave a hospitalization with a specific diagnosis, less likely to have health insurance, and less more likely to experience the stressors of poverty (Sohler & Bromet, 2003).


Working from the assumption that a diagnosis is the first step of a treatment plan we find that an exaggerated, diminished or otherwise mistaken diagnosis can lead to inappropriate treatment and poor management of mental illnesses. If race is a component of such a misdiagnosis, this raises serious issues of social justice and accountability within the psychiatric community.

Situations in which people of color are being misdiagnosed with psychotic disorders can have serious and even irreversible affects on their lives. These patients are likely to go onto intensive treatment in the form of hospitalization, strong medication with strong side effects, or even Electroconvulsive Therapy. If they do not in fact have schizophrenia or psychotic symptoms such so-called treatment would be unethical.

The other manifestations of institutional discrimination mentioned also affect treatment. While not having health care can inhibit early diagnosis, it can severely impact treatment. The Surgeon General has reported that African Americans receive inferior and inadequate treatment for mental illness compared to the population at large (Schwartz, 2009).

One study on diagnosis and treatment of depression in the Latino/Latina community found that issues of language and cultural competence were mitigated in the treatment of depression in states where patients were more likely to be seen by physicians of their own ethnic groups. Furthermore,  successful treatment rates would be higher if education and intervention materials were presented in ways that were culturally appropriate (Simpson, Krishnan, Kunik, Ruiz, 2007). The authors of another study made a similar assertion suggesting that “race matching” between client and clinician should be further explored (Neighbors, Trierweiler, Ford and Muroff, 2003). However, it is not likely that this would be viable in many communities given the disproportionate number of white clinicians.

These studies offer empirical evidence of how clinical psychology has done a disservice to people of color. Conversely, they offer guidance on how the field of psychology and psychiatry can become more culturally competent and maintain its empirical and altruistic integrity. Addressing these issues will lead to better treatment for people of color and a strengthened sense of validity in the field of psychology and psychiatry overall.


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   In P. J. Caplan & L. Cosgrove, Bias in Psychiatric Diagnosis (pp. 71-75).

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Fabrega, H., Jr. (2008, Summer). On the Postmodernist Critique and Reformation

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Haglin, R. P., & Whitbourne, S. K. (2010). Chapter 2: Classification and treatment plans, Chapter 9: Schizophrenia and related disorders. In Abnormal psychology: clinical perspectives on psychological disorders (Sixth ed., pp. 276-305). Boston, MA: McGraw Hill. (Original work    published 1993)


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Simpson, S., Krishnan, L., Kunik, M., & Ruiz, P. (2007, March). Racial

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Sohler, N., & Bromet, E. (2003, March). Does Racial Bias Influence Psychiatric

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