Racial Bias in Psychiatric Diagnosis
Alisha Ali, PhD
New York University
Racial discrimination exists in U.S. society at large and in the healthcare system as a microcosm of the broader society. Given that most healthcare settings function within racist hierarchies (Ali, 2004; Greene, 1995; Javed, 2004), it is not surprising that practitioners commonly perpetuate dominant racial biases. For instance, African-Americans are more likely than whites to be diagnosed with schizophrenia and less likely to be diagnosed with depression (Neighbors, Jackson, Campbell & Williams, 1989; Snowdon & Cheung, 1990; West et al., 2006), and there is evidence that the diagnostic labels assigned can vary based on a host of factors including: the race of the diagnosing practitioner (white vs. African American) (Trierweiler et al., 2006); the type of treatment setting (general care vs. acute care) (Hampton, 2007); the mode of diagnosis (structured vs. semi-structured approach) (Neighbors et al., 1999); and the racial distribution of clients in studies’ recruitment sites (white-dominated vs. racially balanced) (Harralson et al., 2002).
Such findings highlight the insidious nature of bias in psychiatric diagnosis and even call into question the diagnostic categories themselves: If such inconsistencies exist in how psychiatric labels are applied, how valid are these labels? Moreover, receiving a psychiatric label carries considerable stigma and does not necessarily lead to members of ethnic minority groups receiving supportive mental health services; in fact, regardless of their sex, members of those ethnic minority groups are significantly less likely than other people to receive and to benefit from mental health services (McGuire & Miranda, 2008).
Other recent work on the diagnosis of people from ethnic minority groups also leads to serious challenges of the validity of DSM categories. Jonathan Metzl in his recent book, The Protest Psychosis: How Schizophrenia Became a Black Disease (Metzl, 2010), traces the history of the association between the diagnosis of schizophrenia and African-American men and demonstrates that the diagnostic label was applied inordinately often to Black men who had been institutionalized for “violent behavior” exhibited during civil rights protests in the 1960s and 1970s. Women members of ethnic minority groups are faced with the challenge of finding help for their emotional distress while simultaneously having to navigate a system that stereotypes them and their cultures of origin. This stereotyping can take many forms including: the assumption that ”non-Western” cultures condone violence against women and that such violence is therefore a normal part of a woman’s cultural self (Austin et al., 1999); the assumption that a withdrawn and inexpressive nature is always normal for women of certain backgrounds (e.g., Asian, Middle Eastern) and therefore does not indicate emotional suffering (Ali, 2004); ignorance of cultural idioms (Javed, 2004), such as describing the presence or voices of deceased or distant family members; and disregard for the traumatic effects of societal racism on emotional well-being (Pauling & Beaver, 1997).
The central issue underlying the problem of racial bias in psychiatric diagnosis is the dominance of a white, Western viewpoint in psychiatry. Because of this viewpoint, the kinds of behavior most likely to be considered normal in DSM classification are those that are acceptable within mainstream society (Caplan, 1995; Russell, 1994). Even the inclusion of a list of so-called “culture-bound syndromes” in an appendix of the DSM perpetuates this biased viewpoint, because a clinician applying such culture-bound labels is nevertheless expected to adhere to the DSM authors’ approach to diagnostic formulation (Ancis, Chen, & Schultz, 1994). Therefore, rather than only questioning the ability of psychiatrists and other practitioners to apply correctly the codes and labels of the DSM, it is necessary instead to challenge the classification system itself in order to derive alternatives of care that are truly responsive to the needs of minority women and men.
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