Social Class and Classism in Psychiatric Diagnosis

Heather E. Bullock, PhD and Shirley V. Truong, MA

University of California, Santa Cruz

The impact of social class and classism on psychiatric diagnosis remains largely a neglected subject even though a large body of research provides documentation for the far-reaching impact of poverty, and social class more broadly, on people’s psychological and emotional well-being (e.g., APA Task Force on Socioeconomic Status, 2007; Belle & Doucet, 2003; Groh, 2006).

Poor women and women of color are particularly likely to be misdiagnosed or encounter bias in treatment (American Psychological Association, 2007). Therapists may interpret chronic lateness or missed appointments as hostility or resistance to treatment rather than the outcome of unreliable transportation, irregular shift work, and unpredictable childcare arrangements. Therapists may similarly misinterpret a history of being fired or laid off, when, in fact, it is the result of caring for an ill child during the day and spending long nights in the emergency room. Acute distress may be interpreted as an anxiety disorder instead of a consequence of mounting bills, missed meals, and threats of eviction.

The DSM-IV allows practitioners to take poverty and other factors related to class status (e.g., lack of health care, limited access to social services, discrimination, homelessness) into consideration when making primary diagnoses. In principle, this helps situate behavior in a broader social context and focuses attention on environmental sources of distress. Unfortunately, in practice, clinicians often neglect or overlook the diagnostic criteria designated for psychosocial and environmental concerns (e.g., economic problems, occupational problems, legal difficulties, lack of access to health care; Bullock, 2004). As a result, poverty and its consequences are misinterpreted as evidence of an individual’s intrapsychic pathology rather than the result of social inequities and power disparities.

Feminist psychologists advocate for greater attention to social class and its intersections with other social identities (e.g., race, ethnicity, gender, sexual orientation). In part this means attending closely to material conditions and issues of poverty and social class when interacting with clients, drawing conclusions about behavior, making diagnoses, and constructing treatment plans. For practitioners, this will require acknowledging the differential power and privilege (e.g., access to valued resources such as health care and education) that pervade client-practitioner relations as well as broader society, and rejecting intrapsychic interpretations of poverty (see APA Task Force on Socioeconomic Status, 2007; Goodman et al., 2004; Liu, 2001; Smith, 2008, 2009). Equally crucial is critical analysis of how class-based assumptions and classism can be embedded in the diagnostic categories and criteria presented in the DSM, how classism can inform what behaviors are labeled as “dysfunctional,” “problematic,” or “normal,” and how client and practitioner social class can influence the types of diagnoses that are made.

References

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American Psychological Association  Task Force on Socioeconomic Status (2007). Report of the task force on socioeconomic status. Retrieved January 12, 2009,from http://www.apa.org/pi/ses/resources/publications/index.aspx

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Bullock, H. E. (2004). Diagnosis of low-income women. In P. J. Caplan and L. Cosgrove(Eds.), Bias in psychiatric diagnosis (pp. 115-120). Lanham, MD: Rowman &Littlefield.

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Groh, C. J. (2006). Poverty, mental health, and women: Implications for  psychiatric nurses in primary care settings. Journal of the American Psychiatric Nurses Association, 13, 267-274.

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Smith, L. (2008). Positioning classism within psychology’s social justice agenda. The Counseling Psychologist, 36, 895–924.

Smith, L. (2009). Enhancing training and practice in the context of poverty. Training and     Education in Professional Psychology, 3, 84-93.

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