Thomas J. Hernández and Susan R. Seem
State University of New York College at Brockport
Counselor educators have a responsibility to teach students how to ethically diagnose in ways that respect diversity. A contextual understanding of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (American Psychiatric Association, 2000) and an awareness of the individual clinician’s values, and potential biases are essential to ethical diagnosis. This article presents teaching strategies to help counseling students learn how to consider gender and culture in the ethical diagnosis of mental disorders.
Ethical Diagnosis: Teaching Strategies for Gender and Cultural Sensitivity
The counseling profession acknowledges the need to assess and treat pathology. In fact, the American Counseling Association Code of Ethics and Standards (American Counseling Association, 1997) requires that counselors respect diversity, and consider clients’ socioeconomic and cultural experiences when diagnosing mental disorders. Given this, counselor educators have a responsibility to teach students how to diagnose in ways that respect diversity. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) is the tool of choice in the diagnosis of mental disorders. In order to help students learn to diagnose ethically, a contextual understanding of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is essential. Additionally, counselors' values and potential biases impact the diagnostic process (Worell & Remer, 1992). Therefore, this article will place the DSM system in context and examine potential counselor biases. In addition, this article will provide suggested teaching strategies to help counselor education students be sensitive to the issues of gender and culture in the diagnostic process.
The DSM System in Context
Understanding the DSM system in context is important in order for students to learn how to ethically diagnose in a culture and gender sensitive way. The DSM text first emerged as a diagnostic tool for physicians in 1952. Fueled by a psychoanalytic treatment perspective framed in a medical model, the DSM was created to allow medical doctors to speak a similar language. The etiology of psychopathology was seen to reside within the individual, expressed through a patient's neurotic conflict and the diagnostic criteria reflected this premise. Through successive revisions, the DSM-III (1980) and DSM-IIIR (1987) began to adhere to a biopsychological perspective. Additionally, as the revisions occurred, the proliferation of diagnostic labels resulted in approximately a 300% increase in the DSM-IV (1994) and DSM-IV-TR (2000). This was mainly due to insurance companies' need for increasing specificity in diagnoses (Shorter, 1997). Currently, the DSM-IV-TR (2000) rejects the importance of etiology. The diagnostic criteria now reflect a focus on behavioral symptomatology and suggest the importance of drug-management in therapy over psychotherapy (Shorter, 1997). For the first time, the DSM-IV (1994) recognizes the impact of culture on psychological health within a biopsychosocial framework (Smart & Smart, 1997). These points regarding the focus on behavioral symptomatology and the impact of culture on psychological health are also pertinent to the DSM-IV-TR (2000). Thus, the evolution of the DSM reflects the sociopolitical zeitgeist in which it was written and revised.
Although a number of premises of the initial DSM system no longer hold true, there are two basic suppositions that remain throughout all revisions: (1) intrapsychic focus, and (2) the influence of political agendas.
Developed from a medical model perspective, the DSM nosology consistently adheres to an intrapsychic focus. Such a perspective is designed to assist in the diagnostic process in order to prescribe the most effective form of treatment. From this premise, the medical doctor finds physical or internal causes of a disease. Similarly, the counselor using the DSM looks within the individual for a constellation of symptoms that reflect a diagnostic label. The strength of this intrapsychic perspective is the clear behavioral criteria that a client must meet in order to be diagnosed.
Critics, however, argue that the DSM nosology tends to ignore contextual factors involved in symptom development and expression (Rothblum, Solomon & Albee, 1986). For example, few diagnostic categories locate the source of the problem in environmental stressors (Worell & Remer, 1992). Such every day stressors or insidious trauma (Root, 1992) related to “isms” such as racism, sexism, heterosexism, may be denied or minimized.
Personality disorders also serve to illustrate this criticism. The DSM-IV-TR (2000) defines personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2000, p. 685). This suggests that the disorder is located within the individual minimizing the fact that societal norms influence how individuals behave. In fact, Kaplan (1983a) suggests that the DSM codifies exaggerations of women’s gender-role stereotypes. For example, women are socialized to be dependent and emotional, and exaggerations of such behaviors can be diagnosed as dependent or histrionic personality disorders (Brown, 1994; Rienzi & Scrams, 1991). Conversely, overcompliance to male gender roles may result in such diagnoses as antisocial, paranoid, and compulsive personality disorders (Rienzi & Scrams, 1991). In addition, African-American males are more likely to be diagnosed with antisocial personality disorder, because they are socially expected to behave in more aggressive, less-compliant ways (Alarcon, Foulks & Vakkur, 1998). Thus, a client can be diagnosed as a result of overcompliance with stereotypic gendered behavior or racial stereotypes.
While the DSM-IV (1994) maintains an intrapsychic focus, it acknowledges context (e.g., culture, gender, and age) in a variety of ways. The same is true of the DSM-IV-TR (2000). Smart and Smart (1997) state that “the greater cultural sensitivity of the DSM-IV (1994) marks a significant improvement over the previous additions” (p. 392). They outline five new areas of culturally sensitive information that addresses specific cultural features, culture bound syndromes, a formulation to address cultural background, a broader definition of axis four, and the inclusion of new culturally sensitive V-codes. However, this recognition of culture appears largely peripheral. “If linguistic, cultural and social class variability is not identified with the same care as the ‘criteria’ for specific illnesses, then there is a selective inattention to them, a clear statement of their lack of salience” (Dumont, 1987, p. 11).
Influence of Political Agendas
Throughout history, the mere act of diagnosis has been influenced by the sociopolitical and cultural norms of the times, and the same appears true with the development of the DSM (Shorter, 1997). “Significant elements of history and culture, as well as biology in it’s relation to the physical environment, are always incorporated into the way in which illness and problems are presented, interpreted, classified, and treated” (Fabrega, 1992, p. 5). There are a number of examples of the influence of political agendas. First, the DSM-III (1980) labeled homosexuality as a personality disorder. This diagnosis was changed to an ego-dystonic disorder in the DSM-III-R (1987), and ultimately dropped altogether in DSM-IV (1994). The life of this disorder has followed the sociopolitical climate regarding homosexuality in the United States (Bayer, 1981).
Second, Tavris (1992) argued that late luteal phase dysphoric disorder in the DSM-III-R (1987) (renamed premenstrual dysphoric disorder in the DSM-IV (1994)) is manufactured by the media, with extensive credence given to this disorder in historical times when women’s participation in the workforce has been questioned. Further, research on women’s menstrual cycles is rift with flaws in methodology, including insufficient sample sizes, lack of adequate control groups, a focus on negative premenstrual symptoms and inattention to the positive experiences women have in menses, and the generalization from a psychiatric population to all women (Enns, 1997). The assumptions on which research on this disorder is based focus only on negative symptoms and operate on the belief that only females have mood cycles that affect their functioning (Gallant & Hamilton, 1988).
Third, diagnoses in the DSM-II (1968) were based on the assumption of disturbed psychodynamic processes. In contrast, the DSM-IV-TR (2000) views disorders as biological illnesses with emotional overtones. This trend began in the socially and politically conservative 1980’s and managed-care of the 1990’s (Brown, 1994). Brown further argued that the pharmaceutical industry supports such a biological focus because their products depend on the idea of neurotransmitter deficiency as the genesis for client distress. While Enns (1997) declares that the DSM-IV (1994) is "understood as a political and economic document that controls who can provide and receive remuneration for services and often reinforces current hierarchical power structures within society” (p. 280), the same argument is applicable to the DSM-IV-TR (2000). Additionally, funding for diagnostic research is also highly politicized focusing on research projects investigating biological etiology while research that examines environmental causes receive little if no funding (Brown, 1994).
Finally, critics charge that an androcentric bias is present in all revisions of the DSM (Brown, 1994; Unger & Crawford, 1996). The developers of the DSM nosology, predominantly White males with a psychodynamic frame of reference, define what behaviors are viewed as healthy (e.g., autonomy and individualism), and unhealthy (e.g., concern with relationships and dependency). For instance, this bias codifies traditional female gender role behavior (e.g., going to excessive lengths to obtain nurturance and support, having difficulty expressing disagreement with others) as dependent personality disorder. In contrast, the same codification of traditional male gender role behavior (e.g., reluctance to take into account others' needs when making decisions, views work as more important than relationships) is not present (Caplan, 1991; Kaplan 1983a).
Counselors hold assumptions that influence their clinical judgment (Worell & Remer, 1992). Assumptions can be held about gendered behavior and culture. These assumptions can be characterized as cognitive mechanisms (Unger & Crawford, 1996), and individual values and beliefs (Bem & Bem, 1970) that in turn may result in bias (Robertson & Fitzgerald, 1990; Seem & Hernández, 1998; Seem & Johnson, 1998).
In an effort to make sense of an otherwise chaotic world, counselors, and indeed all humans, have a tendency to create order where none apparently exists. For example, people use race, sex, and age as social categories of organization in understanding others and in so doing encode information about others based on those categories (Unger & Crawford, 1996). People tend to have selective recall, distorting images of an individual to more closely match stereotypic representations of the group to which he or she is ascribed. Therefore individuals' erroneous inferences about others can influence their perceptions. Fundamental attribution error, for example, is the tendency to underestimate the influence of situations on others' behavior and to exaggerate the effect of their individual personalities (Morrow & Deidan, 1992; Unger & Crawford, 1996). Such cognitive shortcuts accelerate the decision-making process but may result in counselors attending to information that confirms beliefs about a client's social category. Consequently, counselors are not immune from using cognitive mechanisms to understand their clients.
Potential for Counselor Bias
Counselors are inculcated with the dominant culture’s values and beliefs about mental health and illness. Thus counselors acquire a nonconscious ideology (Bem & Bem, 1970) that may remain unquestioned in the practice of diagnosis. The dominant group’s power obscures the relationship between dominance and subordinacy. Thus, the dominant ideology about normalcy and psychopathology becomes nonconscious. This nonconscious ideology may include such “isms” as sexism, racism, heterosexism, and ableism. Unless made aware of this nonconscious ideology, counselors are likely to operate from this dominant perspective and not question its ideology.
Additionally, the definition of mental disorder allows for counselor subjectivity. The definition of mental disorder makes this nosology susceptible to bias in the DSM-III-R (1980) (Russell, 1986) and subsequently the DSM-IV-TR (2000). A mental disorder is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful system) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom”(American Psychiatric Association, 2000, p. xxxi). This definition allows the clinician to decide what is distressful and what is disability. Further, in its discussion of clinical judgment, the DSM-IV-TR (2000) states that the "exercise of clinical judgment may justify giving a certain diagnosis to an individual even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms present are persistent and severe”(p. xxxii) [italics added]. Counselors, therefore, have a great deal of diagnostic leeway in determining whether or not a diagnosis is given. Consequently, values, biases, theoretical orientation (Worell & Remer, 1992), social status, privilege, and power may influence diagnostic judgments.
Suggested Teaching Strategies
Counseling itself is a sociopolitical act (Katz, 1985). The development of a relationship between any two people necessarily suggests an intercourse about personal, social and political assumptions and values. “We cannot judge without having power. If we judge from the standpoint of one culture to the detriment of a client (or trainee) of another, we have committed a political act” (Bernard & Goodyear, 1992, p. 198). Diagnosis involves the use of judgment. The following strategies are suggested as a way to teach ethical diagnosis with attention to gender and culture. Because of limited space, a number of references are included to serve as resources.
Strategies to Address DSM-IV-TR in Context
One way to help students use the DSM-IV-TR (2000) with gender and culture sensitivity is to help them understand the context in which the DSM was developed and is used. This involves discussing the history of mental disorders starting with early diagnosis and treatment of behavioral disorders in ancient cultures, European cultures in the Middle Ages, slavery in the United States (Landrine, 1988) and the present (Shorter, 1997). This includes how different cultures define, diagnose, and treat psychopathology (Castillo, 1997; Landrine, 1988; Matsumoto, 1996; Pedersen, 1987). It is important for students to understand that what is defined as psychopathology are those characteristics that differ from the dominant culture’s definition of normalcy, and vary over time and with culture.
In discussing the history of the DSM system itself, an understanding of the people and the culture in which the DSM system was developed, the process of inclusion and exclusion of diagnostic labels, and the appearance and disappearance of labels is essential (Bayer, 1981; Brown, 1994; Caplan, 1991; Kaplan 1983a; Kaplan 1983b; Rubinstein, 1995; Tavris, 1992). How power and dominance interact with psychopathology in a social context also needs to be considered (Collins, 1998). Perhaps most important is an understanding of the social and political meanings of labels (Gallant & Hamilton, 1988; Kirk & Kutchins, 1992; Kutchins & Kirk, 1997). That is, students can be engaged in discussions about their own personal definitions of psychopathology, and the societal and historical meanings of certain diagnostic labels. Finally, students need to understand that mental disorders can be reliably predicted by gender, ethnicity and socioeconomic status (Landrine, 1988).
Strategies to Address Counselor Awareness
Values, beliefs, and cognitive mechanisms influence how diagnostic judgments are made. Consequently, students' awareness of their own values and beliefs about mental disorders and the sociocultural genesis of those beliefs need to be fostered (e.g., gender role stereotypes, cultural expectations, behaviors of subordinate and dominant groups) (Bem & Bem, 1970; Broverman, Broverman, Clarkson, Rosenkrantz & Vogel, 1970; Caplan, 1991; Faludi, 1991; Luske, 1990; Miller, 1986; Pedersen, 1987; Pollack, 1998; Ritchie, 1994).
One way to examine specific cognitive mechanisms, values, and beliefs that students use to make diagnostic decisions is to provide case descriptions that give behavioral descriptions of an individual's behavior, but exclude social categories such as gender, age, social class, race and ethnicity. Students are asked to provide a diagnostic label for the client and to describe the client's appearance. This results in a dialogue in which students become aware of how they might diagnose individuals based on perceived social categories, and individual values and beliefs.
Gender and Culturally Sensitive Strategies
Students need the opportunity in the classroom to experience the diagnostic process. Providing students with case vignettes for triadic role-playing exercises and group discussion allows for practice in conducting gender and culturally sensitive diagnoses. Role-playing facilitates experiential learning about the process of diagnosis, the manner in which counselor-client interactions affect diagnosis, and what it means to arrive at a gender and culturally sensitive diagnosis in the context of a safe, classroom environment. Triadic role playing entails groups of three students each taking on one of three roles: Counselor, client, and participant- observer. The latter provides feedback to the counselor and serves as a resource to both throughout the exercise. Case vignettes can be developed to include various cultural and gender phenomena. The following case study example is an attempt to present not only depressive symptoms, but also features of dependent personality disorder. Choosing symptoms from mood disorders and personality disorders simultaneously may tap potential biases and will help students realize that some diagnostic labels are more value-laden than others are. This vignette also addresses potential cultural structures present in presenting symptoms. With this example, students can experience the complexity of the diagnostic process, their own biases surrounding symptomatology, and how culture may influence symptomatic presentation and clinical perceptions of these symptoms in diagnosis.
Information for counselor and client: The client is a 24-year-old Cuban-American female. She comes to your office looking and sounding timid, and unsure of herself. She is wearing a baseball cap, low over her forehead, a flannel shirt that is untucked and a pair of torn jeans. One of her sneakers is untied. Her eyes appear swollen with tears during the intake interview. She makes poor eye contact. She expresses feeling sad, worthless, indecisive, and has been thinking about death. She seems to need reassurance from her husband and family, and lacks confidence in herself. She is afraid of losing her husband's support. She has experienced these feelings for the past two years. They have intensified recently. The client is having difficulty sleeping, feels unmotivated, and "can't seem to get of bed in the morning."
Additional instructions for the client only: You are in an abusive relationship. You present yourself as worrying about his needs and wanting him to take responsibility for what goes on in your life, and needing his approval for all things you do. You are terrified because he is unaware of your seeking help and you are afraid you will lose his love and support. Your family reminds you that you must remain committed to your relationship.
The following steps are suggested as ways to help students process this case. Prior to the role-play, students are presented first with the case description and a class discussion ensues defining areas they need to investigate during the role-play in order to make an accurate diagnosis.
Second, the role-play occurs and students use the prior discussion to formulate emergent questions. The counselor can, during the role-play, ask for assistance, if needed, from the participant-observer. After completion of the role-play, the counselor and participant-observer consult and arrive at a diagnosis. Part of this diagnostic decision making process is for the counselor and participant-observer to engage in a discussion about the diagnostic criteria, and the contextual meanings of the client's symptoms. Questions can be derived from the following areas: Cultural systems and structures (e.g., coping patterns that may be culturally based), cultural values (e.g., areas related to time, activity, and relational orientation), and the effect of trauma (e.g., place the client's experience in a sociopolitical context, and understanding the client's subjective experience of the trauma) (Sinacore-Guinn, 1995). In addition, Brown (1990) suggests conducting a gender role analysis that explores such areas as gender role socialization, the meaning of gender within the client's family and culture of raising, gender role compliance or non-compliance, and the presence of gendered low and high base rate phenomena. Additional areas to consider are culture-specific norms and the client's conformity or nonconformity with perceived cultural behavior patterns (Lopez, 1997). Explorations of these areas assist the counselor in better understanding the client's presenting concerns within her or his context.
Third, after arriving at a diagnosis, the triads share with the whole class their diagnostic decision and the reasons why they arrived at such a label. A class discussion occurs about the appropriateness of the diagnostic labels. As a part of this discussion, students are encouraged to develop alternative hypotheses about why the client is feeling, thinking, and behaving, and presenting the way she is. This involves examination of situational factors and client data that on the surface may appear to be less significant (Morrow & Deidan, 1992). This type of discussion assists students in understanding how the premises of the DSM system, their own values and biases, and their own cognitive maps may influence the diagnostic process.
Finally, students need to be aware that they are operating within two cultural perspectives - theirs and that of their clients' (Lopez, 1997). A part of a gender and culturally sensitive diagnostic process is learning to give equal credence to both counselors' interpretation of their clients' experiences and to the meanings that clients' give their experiences (Brown, 1990; Lopez, 1997; Morrow & Deidan, 1992; Sinacore-Guinn, 1995). Each counselor in the triad provides a rank ordered list of the most salient factors used in the development of the diagnosis. Differences in rank ordering among counselors will most likely occur, and this leads to a discussion of the impact of counselor interpretation in the diagnostic process. Finally, clients rank order what was most important to them in their understanding of their experience. There is likely to be differences between counselors' and clients' interpretations. This exercise fosters an awareness of counselors' power in the diagnostic process and the need to share that power with clients.
Diagnosis is indeed a complex process. Because many counselors are required to make diagnoses as part of their employment, it is essential that diagnosis be done with gender and cultural sensitivity. By extension, the training of students needs to include opportunities for students to explore their own values and biases, understand the context of the DSM, and to practice the art of diagnosis. The strategies included here are by no means exhaustive, but are presented as one way to help students learn to diagnose in an ethically and diagnostically sound fashion.
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