Differences in Mental Health Counselors' Diagnoses Based on Client Race: An Investigation of Adjustment, Childhood, and Substance-Related Disorders
Feisthamel, Kevin P., Schwartz, Robert C., Journal of Mental Health Counseling
This study of mental health counselors' diagnoses of African-American and Euro-American clients (N=899) found that African-Americans were diagnosed disproportionately more often with disruptive behavior disorders whereas Euro-Americans were diagnosed more often with less severe adjustment disorders. These findings mirror those of researchers from other mental health professions considering different mental disorders. Implications for mental health counseling practice and future research are discussed, and pathways to account for the phenomenon are proposed.
Although almost 300 distinct mental disorders are identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, APA, 2000), only a small fraction have been studied in terms of whether race affects clinician diagnostic decisions. Researchers have primarily studied whether psychotic and mood disorders are diagnosed more often among clients from different racial backgrounds (Baker & Bell, 1999). Because clients' presenting symptomatology is often complex and clinical diagnoses ultimately have a subjective component, clinicians may unwittingly diagnose mental disorders inaccurately (Sohler & Bromet, 2003; Bell & Mehta, 1980). Erroneous diagnoses can lead to negative consequences for clients (e.g., social stigma, loss of freedom); the counseling profession (e.g., loss of credibility); the mental health field (e.g., mistrust); and society in general (e.g., inaccurate identification of mental disorders resulting in misdirection of funding).
Differential rates of certain diagnoses may be common among clients of color (Feisthamel & Schwartz, 2007). In particular, higher rates of more impairing diagnoses have been found among African Americans than among Euro-Americans. For example, Flaskerud and Hu (1992) found that African Americans who reported suspiciousness and unusual perceptual experiences were more often diagnosed as having schizophrenia than other groups. Fabrega (1996) noted a low proportion of African Americans with mood disorders and a higher than average proportion with psychotic disorders. Similarly, Lawson, Hepler, Holladay, and Cuffel (1994) found that in a sample of over 11,000 clients African Americans were considerably overrepresented among those with diagnoses of schizophrenia and underrepresented among those with mood disorder diagnoses (see also Snowden and Cheung, 1990, and Strakowski et al., 1995). More recently, Foulks (2004) and Neighbors, Trierweiler, Ford, and Mufoff (2003) also reported elevated frequencies of schizophrenia and other psychotic disorder diagnoses among African Americans and mood disorders among Euro-Americans. As Baker and Bell (1999) stated, one of the primary causes for more inpatient admissions among African American clients could be higher rates of more severe mental disorder diagnoses. Lawson, Hepler, Holladay, and Cuffel (1994) reported that African Americans are more likely than Euro-Americans to be hospitalized in psychiatric units and to be involuntarily committed. Regarding treatment decisions, Barlow (1993) explained that mood disorders usually require less persistent and invasive interventions than psychotic disorders. Thus, a mood disorder diagnosis may represent a more "cautious" approach by the diagnostician (Feisthamel & Schwartz, 2006a)--an approach that clients of color do not seem to benefit from.
Methodological limitations of many research studies in this area include small sample sizes and outdated, often less reliable (pre-DSM-IV), diagnostic criteria. Perhaps the most notable limitation of prior research on diagnostic differences was that studies were restricted to psychologists and psychiatrists. Therefore, through specialized training and ongoing advocacy, CACREP (2001) and counseling organizations promote the professional practice and identity of professional counselors. This effort includes research related specifically to the counseling practice. …