The shooting of an unarmed teenager in Ferguson, MO, has ignited a global discussion about implicit racial bias. One group of people you might think would be immune from this hidden bias is clinical therapists, people trained to understand the human mind. But a new field study finds that the social identities of patients and their therapists affect the accuracy of the diagnosis: Therapists were twice as likely to misdiagnose mental illness when their patients were members of a disadvantaged, compared to an advantaged, group.
In her own practice, Ora Nakash, a clinical psychologist at the Interdisciplinary Center in Herzliya, Israel, began wondering how the social identities of her clients were affecting her decision-making process. "For example, a White therapist can interpret affect disregulation symptoms of a client who is also White as rooted in financial pressures and diagnose him/her as having transient adjustment disorder," she explains. "Conversely, if the client is African American, the same symptoms might be seen as proof of the client's persistent borderline personality disorder."
In a previous study, Nakash found that even with similar information collected during the mental health intake, clinicians weighed the information differently to assign a diagnosis depending on patients' ethnicity or race. "Here, we wanted to check if the therapist's social identity might impact the diagnostic decision-making process as well," she says.
So Nakash and colleague Tamar Saguy took to the field, investigating regular practice in community mental health clinics in three large cities in Israel that serve mostly low- to middle-class populations. The study focused on differences between encounters involving Mizrahi (Jews of Asian/African descent) and Ashkenazi (Jews of European/American descent) patients.
"These ethnic groups are interesting both in the context of the Israeli society, as they make up the majority of the Jewish population in Israel, but also in the broader context of mental health disparities," Nakash explains. "We know that minority groups, including migrants and ethnic minorities in many Western societies, tend to receive lower quality mental health care and may suffer from greater risks for mental illness." Both the Mizrahi and Ashkenazi migrated early in the history of Israel, making it easier for the researchers to investigate the effects of belonging to a disadvantaged ethnic group while controlling for the effects of migration.
The researchers followed patients during the intake sessions with their therapists. Afterward, they asked the patients to complete a separate structured diagnostic interview (called the MINI) with an independent interviewer. Therapists also completed study measures immediately following their sessions. Comparing the therapists' evaluation with the evaluation obtained from the independent interview provided the researchers a measure of diagnostic accuracy.
Nakash and Saguy were surprised at the magnitude of the differences in the accuracy of diagnosis they found. "Even in a clinical setting, which offers conditions to overcome bias in decision-making - motivation to help, and time and space to collect ample information to overcome stereotypical thinking - we see that misdiagnosis is almost twofold when a socially advantaged therapist meets a socially disadvantaged client compared to seeing a socially advantaged client." They also found that the quality of the rapport was worse in these encounters, as published in the journal Social Psychological and Personality Science.
"This study is the first to empirically examine diagnostic accuracy in the context of mental health intakes when considering the identity of the client and therapist," Nakash says. "If members of disadvantaged groups are more frequently misdiagnosed relative to advantaged group members as indicated by our findings, it is no surprise that the quality of the mental health services they receive, and their mental health outcomes, are worse."
The findings, they say, have important implications to clinical practice and training. They hope the study will be a call to action for the clinical community. "Our study has implications both to the need to rethink clinical training as well as increase the ethnic diversity of mental health providers.," Nakesh says. "As consumers of mental health services, I believe clients should ask about their therapist's experience and training working with diverse client population." She adds that cultural competence training should be part and parcel of educational and training programs for all mental health providers.
As to why this dynamic occurs in the clinical setting, the researchers are still investigating potential reasons. It could be due to favoritism for people similar to the therapists or could be a result of cross-cultural difficulties. In future work, the researchers hope to study how different mechanisms, such as ability to take the other person's perspective, may explain, or even help curb, some of the diagnostic bias.
"The ultimate goal of our work is to develop intervention programs for therapists training to improve diagnostic accuracy in the work with diverse client population," Nakash says.