A mixed methodological analysis of the role of culture in the clinical decision-making process

Continued demographic shifts in the U.S. population whereby the proportion of racial/ethnic minorities is increasing (U.S. Census Bureau, 2000), coupled with more attention to social injustices for typically oppressed groups (e.g., racial/ethnic minorities, women, sexual minorities), illuminate that the counseling profession is becoming more complex. To this end, professional counselors must adapt their clinical decision-making processes to accommodate a more diverse population. Clinical decision making refers to the intricate decisions professional counselors make when they assess the degree of severity of a client's symptoms, identify a client's level of functioning, and make decisions about a client's prognosis. Prevalence data for racial/ethnic minorities, women, and sexual minorities show disproportionate rates of assessed mental illness. For example, Hispanics have been diagnosed with schizophrenia 1.5 times the rate of Whites, and African Americans are more likely than Whites to be diagnosed with schizophrenia, substance abuse, and/or dementia (see Block, 1984; DelBello, Lopez-Larson, Soutullo, & Strakowski, 2001; Jones & Gray, 1986; Mukherjee, Shukla, Woodle, Rosen, & Olarte, 1983; Strakowski, Shelton, & Kolbrener, 1993). Women are disproportionately diagnosed with personality disorders (Eriksen & Kress, 2005; Ford & Widiger, 1989); lesbian, gay, and bisexual clients are diagnosed 3 times and 4.7 times the rate of heterosexual clients for major depression and panic disorder, respectively (Cochran, Sullivan, & Mays, 2003); and clients of lower educational levels are diagnosed more often with schizophrenia than with mood disorders (Paniagua, 2005). The principal question, then, is whether these differences in diagnostic rates are actual differences among cultural groups or whether they are more reflective of bias in decision making among practitioners. That is, are counselors diagnosing accurately, or is misdiagnosis based on cultural differences the cause of the discrepancy in these rates? Researchers highlighting the disproportionate prevalence of particular diagnoses among individuals for diverse identities argue that these rates result from individuals belonging to typically oppressed groups (e.g., racial/ethnic minorities, women, sexual minorities) being diagnosed with more severe diagnoses. Alternatively, available empirical data suggest that some clients may receive less severe diagnoses if symptomatology does not fit an existing diagnostic criteria set (Eriksen & Kress, 2005; Lin, 1996) or is congruent with cultural roles or stereotypes associated with a particular gender or race/ethnicity (Block, 1984; Lopez, 1989). Furthermore, similar symptoms may be judged less severe depending on either the amount of resources practitioners perceive certain clients to have (Lopez, 1989) or the awareness of the role environmental factors has on the perpetuation of mental illness, such as having a strong situational locus of attribution (Gushue, 2004). An increased understanding of whether diagnostic variance (and thus misdiagnosis) exists disproportionately among culturally diverse groups could address the question of whether disproportionate rates are real or not. Unfortunately, there is minimal literature available on diagnostic variance in counseling in general and, more specifically, on the role culture plays in variance. Diagnostic variance refers to the notion that professional counselors display variability in how they arrive at clinical decisions (Hays, McLeod, & Prosek, 2009). Some forms of diagnostic variance include divergent expressions of symptoms across individuals for mental disorders, differences in the amount and type of data that are collected from clients, varying interpretations of the same data among professional counselors, and the differential application of criteria in the diagnostic process (Gigerenzer, 2002). Even with the predominant use in the counseling profession of the Diagnostic and Statistical Manual of Mental Disorders (4th ed. …