By Jocelyn Markowicz, PhD, Psychologist

Turn It Upside Down: From the Existing Model to the Anti-Racist Model of Diagnostic Care for African Americans

As the world copes with a global pandemic, a historical pandemic has also been illuminated: the racism pandemic. We are becoming increasingly aware of the biases inherent in the structures that frame our society, and the need to enact change is urgent. If we accept the premise that existing systems are racist, we need to turn them upside down to achieve non-racist outcomes. As a psychologist, while I am aware of the macro-level processes that proliferate racism, I also focus on micro-level processes that further crystalize systemic racism. To this end, I would like to highlight the racist diagnostic process that has impacted African American mental health treatment.   

The Current State Is Unacceptable

What we know about the mental health treatment of African Americans is that it is fraught with racist practices from treatment access problems (Akutsu, Snowden & Organista, 1996; Takeuchi & Cheung, 1998) to poor treatment outcomes (Agency for Healthcare Research & Quality, 2008, 2012, 2018). African Americans are routinely inaccurately diagnosed with serious mental illness (Delphin-Rittmon, et al., 2015; Snowden & Cheung, 1990; Lawson et al., 1994; West et al., 2006).

In a 2018 meta-analysis, diagnostic biases against African Americans were documented to have persisted for three decades (Olbert, Nagendra, & Buck, 2018). You may be asking, “How does this diagnostic bias that occurs within African American mental health care compare to the diagnoses received by their Caucasian American counterparts?” The 2018 meta-analysis determined that when both groups present to treatment with the same symptoms, it is the African American patient who is diagnosed with the most severe mental disorder. 

Time to Turn It Upside Down

So, if diagnostic racism is systemic, what do we do to change it? We must turn the racist system upside down to achieve the unexpected: anti-racist diagnostic care. Here are four critical steps toward anti-racist diagnostic care for African Americans. Completion of these four steps will turn the anti-racist diagnostic model upside down leading to greater accuracy and more effective care.

Anti-Racist Diagnostic Model 

Step 1:  When an African American client comes to treatment, write down the least severe diagnostic hypothesis first. How is this different than the existing racist diagnostic model? In the racist diagnostic model, the clinician writes down their first diagnostic hypothesis, and research has shown, across decades, that despite the same presenting symptoms, African Americans are diagnosed with the most severe diagnoses versus their Caucasian American counterparts (Olbert, Nagendra, & Buck, 2018). This practice will help you fully consider the range of diagnoses. 

Step 2: Gather evidence to support the presence of the least severe diagnosis. How is this different than the existing racist diagnostic model? Racial bias is demonstrated in the determination of the presence of a severe mental disorder for African Americans compared to Caucasian Americans with the same symptom presentation (Olbert, Nagendra, & Buck, 2018). This pattern highlights the automatic influence of racial bias. To challenge automatic biases, psychologists must engage in a cognitive process designed to do the opposite of their preconceptions. This anti-racist model does just that. Looking for evidence to support the least severe diagnosis slows your automatic thinking, allowing more time for you to challenge initial diagnostic biases that would go unchecked if you went with your initial impression only. Research as recent as 2020 continues to show that slowing down thinking leads to greater accuracy (Lawson, Larrick, and Soll, 2020).

Step 3: Gather evidence to support an alternative diagnosis that could be more severe. How is this different than the existing racist diagnostic model? Automatically assigning the most severe diagnosis to an African American patient does not challenge the racial bias that has led to a persistent diagnostic inaccuracy. The anti-racist model challenges this automatic process by first looking for the least severe and then challenging that premise by evaluating competing information that may yield a diagnostic decision toward the presence of a more severe disorder. The task is to challenge automatic racial biases by slowing down the critical analysis in order to incorporate supporting and competing symptom evidence. 

Step 4: Review all available data to support the least and most severe mental disorders. Engaging in this process further slows the psychologist’s instinctive thinking process down and allows space to be a critical thinker of all available data to make an accurate diagnosis. It is in this slower process wherein biases can be challenged. In this space, psychologists can alter internalized diagnostic racism by actively challenging their biases so that they do not get in the way. This process does not restrict the psychologist from accurately diagnosing more severe conditions, but it does limit a psychologist’s instinctive bias to inaccurately diagnosis based on racist beliefs.  

Applications in Supervision and Continuing Education

This upside-down diagnostic process is helpful only if psychologists have consultation partners to ensure that they have engaged in the critical analysis that examined biases that could have impacted their diagnostic decisions. Thus, supervision should include anti-racist diagnostic training. Psychologists under supervision should have support in slowing down their diagnostic decisions in order to increase non-racist diagnostic practices. Supervisors should be specifically trained to provide supervisees with the anti-racist, upside-down diagnostic method. Fully licensed psychologists should be required to participate in anti-racist diagnostic strategy continuing education. As it stands now, diversity training for psychology trainees indicates that knowledge gained about different cultures increases and persists long-term, but attitudinal change that influences racist behaviors does not persist long-term (Bezrukova, Spell, Perry, and Jehn, 2016). Both cultural knowledge and attitudinal change are needed to reduce biases in diagnostic decisions.

In Conclusion

The anti-racist diagnostic model that I offer does indeed turn the current racist process on its head. You may be wondering why we have not engaged in this process before? Racism persists because of the systems in place that maintain it. On a macro-level, the field of psychology has worked actively to implement diversity training programs and cultural competency standards. However, greater diligence is needed to develop and implement micro-level training to address racism in diagnostic decisions for African Americans. Turning the current racist diagnostic process upside down will reduce the impact of biases on diagnostic decisions, leading to more accurate diagnoses and treatment intervention.

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References

Agency for Healthcare Research and Quality. (2008). 2007 National healthcare disparities report. Rockville, MD: Author.

Agency for Healthcare Research and Quality. (2012). 2011 National healthcare disparities report. Rockville, MD: Author.

Agency for Healthcare Research and Quality. (2018). 2017 National healthcare disparities report. Rockville, MD: Author.

Akutsu, P.D., Snowden, L.R., & Organista, K.C. (1996). Referral patterns in ethnic-specific and mainstream programs for ethnic minorities and whites. Journal of Counseling Psychology, 43, 56-64.

Bezrukova, K., Spell, C. S., Perry, J. L., & Jehn, K. A. (2016). A meta-analytical integration of over 40 years of research on diversity training evaluation. Psychological Bulletin, 142(11), 1227–1274. https://doi.org/10.1037/bul0000067

Delphin-Rittmon, M.E., Flanagan, E., Andres-Hyman, R., Ortiz, J., Amer, M. (2015). Racial-Ethnic Differences in Access, Diagnosis, and Outcomes in Public Sector Inpatient Mental Health Treatment. Psychological Services. 12(2), 158-166.

Lawson, M.A., Larrick, R. P., & Soll, J.B. Comparing fast thinking and slow thinking: The relative benefits of interventions, individual differences, and inferential rules. Judgment and Decision Making, Vol. 15, No. 5, September 2020, pp. 660-684.

Olbert, C. M., Nagendra, A., & Buck, B. (2018). Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities? Journal of Abnormal Psychology, 127(1), 104–115.

Snowden, L.R., & Cheung, F.K. (1990). Use of inpatient mental health services by members of ethnic minority groups. American Psychologist, 45, 347-355.

Takeuchi, D.T., & Cheung, M.K. (1998). Coercive and voluntary referrals: How ethnic minority adults get into mental health treatment. Ethnicity & Health, 3, 149-158.

West, J.C., Herbeck, D. M., Bell, C.C., Colquitt, W.L., Duffy, F.E., Fitek, D.J., Narrow, W.E. (2006). Race/ethnicity among psychiatric patients: Variations in diagnostic and clinical characteristics reported by practicing clinicians. Focus (American Psychiatric Publishing Online), 4, 48-56.

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