Racial Bias
in
Clinical Practice
by José M. Abreu, Ph.D.
|
Clinical studies have consistently reported negative biases toward minority clients in terms of diagnosis and treatment. Baskin, Bluestone and Nelson (1981a), for example, found that White and Asian clinicians diagnose higher levels of psycho-pathologies in Black clients than Black or Hispanic clinicians. Correspondingly (Baskin et al., 1981b), the authors reported that Black women were diagnosed more often as psychotic and less often as depressed than women of other races. Jones (1982) reported that White therapists gave more severe diagnoses to Black clients than White clients. In addition, Snowden and Cheung (1990), and later Paradis et al. (1994), reported that African-Americans were more likely than Whites to be diagnosed with psychotic disorder over affective disorder. |
While clinical studies have consistently reported negative biases toward minority (particularly, Black) clients in terms of diagnosis and treatment, analogue studies generally find no bias among participating counselors (e.g., Littlewood, 1992), or even a "pro-Black" bias (e.g., Strickland, Jenkings, Myers and Adams, 1988). For these studies, clinical materials such as audio-taped interviews or case summaries are presented to clinicians who are asked to provide clinical ratings on clients identified as either Black in one condition, or White in the other. Some writers attribute these analogue findings to social desirability response sets occurring when client race is a transparent variable of interest. In other words, perhaps participants may "discern the true objectives of the study and adjust responses so as to put themselves and their profession in a favorable light" (Abramowitz and Murray, 1983, p. 218). In contrast, participants in studies based on actual clinical data are generally not aware that their clinical judgments are part of an investigation.
When analogue studies involving client race are designed to circumvent or minimize social desirability responses, counselor responses generally manifest biased perceptions (e.g., Abreu, 1999; Casas, Wampold and Atkinson, 1981). In Casas et al. (1981), counselor trainees were to make judgments of hypothetical students based on recall of information previously presented relating to ethnicity, blood type and stereotypical characteristics. Casas et al. found that when recalling information about minority targets, Anglo-American trainees made fewer errors on those for which a stereotypical response was correct than on those for which the stereotypical response was incorrect. This observation indicates that respondents were more prone to be influenced by ethnic stereotypes compared to their ethnic minority counterparts.
The results of my recent publication (Abreu, 1999) have added further strength to the hypothesis that therapist racial bias is associated with perceptual processes involving racial stereotypes. For this study, I used a procedure to induce subjects to think of racial stereotypes without realizing they were doing so. On computer screens, I flashed a word series at about one-tenth second apiece before 60 therapists or therapists in training. That's fast enough to enable visual perception but insufficient to allow conscious processing of the words. To circumvent social pressures against revealing racial bias, I concealed the study's real purpose by saying the study assessed "visual-spatial differences" among subjects.
Half of the participants (control group) were shown a series of words without racial connotations (i.e. water, then, about, things and thought). But most of the words shown to the other participants (experimental group) played into African-American stereotypes (i.e. rhythm, ghetto, welfare, basketball and plantation). The subjects then read a description of fictitious Mr. X, "a man referred for psychological treatment," and an excerpt from his therapy session. The patient's race was not identified, but therapists in the experimental group assumed Mr. X to be African-American, while the control subjects did not. Participants were then asked to rate their general impressions of Mr. X (how hostile or kind he seemed, for example) on an 11-point scale ranging from 0 (not at all) to 10 (extremely). They also rated how likely the patient was to suffer from one of eight mental illnesses or conditions, using the same scale. Finally, subjects were informed that Mr. X was black and were asked to once again give their general and diagnostic impressions.
When initially asked to give their impressions, subjects who had been primed to assume the patient was African-American were far more likely than the control-group subjects to view him as hostile. Indeed, 70 percent of the former did so, compared with 40 percent of therapists who were exposed to neutral words. This finding shows that racial stereotypes can negatively affect the therapists' view of patients. On the other hand, subjects exposed to stereotypical words were no more likely than control-group subjects to give Mr. X higher ratings on the eight diagnostic categories. Thus, more research is needed to ascertain whether the impressions distorted by racial bias may lead to incorrect or exaggerated diagnoses. In any event, subjects dramatically adjusted their general impression ratings after learning that Mr. X was African-American. When the patient's ethnicity was explicitly identified, more therapists rated him as less hostile and more rated him as less pathological. In experimental (but not clinical) settings social desirability pressures appear to motivate therapists to adjust their impressions when they consciously know the patient's race, which may be why past experimental research has failed to uncover racial bias.
Training Implications
The research evidence indicating the presence of racial bias in clinical practice highlights the need for mental health practitioners to pay attention to this issue. Sue, Arredondo, and McDavis (1992) identified three competencies that characterize a culturally skilled mental health practitioner:
(a) knowledge about diverse cultures;
(b) ability to use intervention skills or techniques that
are culturally responsive, and
(c) awareness of personal beliefs/attitudes toward
culturally diverse clients.
Arredondo et al. (1996) outline training implications for "knowledge," "skills," and "awareness," competencies. The operationalizations of a competent mental health practitioner in the cultural knowledge area, for example, include "can discuss recent research addressing issues of racism, White identity development, antiracism and so forth" (p. 60) and "can describe at least two different models of minority identity development and their implications for treatment" (p. 64). Competent practitioners in the area of technical skills "can give examples of how they may modify a technique or intervention or what alternative intervention they may use to more effectively meet the needs of a client" (p. 71), and "can describe concrete examples of situations in which it is appropriate and possibly necessary ... to exercise institutional intervention skills on behalf of a client" (p. 71). Competence in attitudes and beliefs requires practitioners to "identify social and cultural influences on their cognitive development and current information processing style" (p. 60) and "recognize their stereotyped reactions to people different from themselves ... consciously attend to examples that contradict stereotypes ... [and] give specific examples of how their stereotypes ... can affect the ... client" (p. 63).
Coursework readings or presentations on racial/gender/sexual identity development, acculturation theory, sociopolitical histories of minority groups that emphasize the impact of oppression on self-concept and the teaching of techniques particularly suited for specific cultural groups can be expected catalysts to cultural "knowledge" and "skills" competencies as defined by Arredondo et al. (1996; see Brown, Parham and Yonker, 1996). Educational approaches designed to promote awareness of racism and other biases typically rely on experiential exercises and activities to prompt participants to start thinking of themselves as racial beings.
Conclusion
In reviewing literature documenting mounting evidence
of racial bias in clinical practice, Adebimpe (1994) concluded, "the evidence of different treatment experiences can no longer be regarded as "scanty, piecemeal and inconclusive" or as an artifact of a transient period of heightened research interest in blacks" (p. 30). It is with good reason that writers in this topical area (Axelson, 1985; Ridley, Mendoza, Kanitz, Angermeier and Zenk, 1994; Wintrob and Harvey, 1981) have long cautioned practicing mental health professionals to pay particular attention to themselves when working with ethnic minority clients to "ferret out private agendas and actively work to eliminate their prejudicial or stereotypical perceptions of culturally different clients" (Ridley et al., 1994 p. 131).
In this interpretation of The Wizard of Oz, the Tin Man masculine element does not evolve into
José M. Abreu is a 1995 recipient of a Ph.D. in Counseling Psychology from the University of California, Santa Barbara. Another major professional interest for him is in multicultural (or cross-cultural) counseling, often termed the "fourth force in psychology." Dr. Abreu may be contacted at: Jose M. Abreu, Ph.D., Division of Counseling Psychology, WPH 503—University of Southern California, Los Angeles, CA 90089-0031. You may also contact Dr. Abreu via e-mail at abreu@mizar.usc.edu.
References
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