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.
Language
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).
Conclusion
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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