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Harvard Commentaries
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Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Understanding Bias In Mental Health Professionals

October 17, 2012

By Michael Craig Miller M.D.

Harvard Medical School

A study published in the Journal of Consulting and Clinical Psychology in 2007 showed that personal and professional biases can affect first impressions and the label used by mental health professionals to diagnose a person's mental disorder. (Bias occurs when personal preference interfere's with a person's ability to make an impartial judgment.)

Who is making the diagnosis may matter. To avoid bias, the best approach may be to see a diagnosis as part of a process that occurs over time rather than as something based on first impressions and set in stone.

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How the Study Was Done

Nearly 1,400 psychiatrists, psychologists, and social workers — a representative professional sample — participated in the study. Researchers mailed each of them one of three fictional case studies describing a troubled teen. Symptoms were typical of someone with a conduct disorder: persistent anti-social behavior including deceit, theft, aggression, truancy and running away from home. Conduct disorder was chosen because it's the most common reason for referring adolescents for treatment. In some case histories the young man was described as white, while in others he was black or Hispanic. Here are the three types of case histories that were used:

  1. Neutral version – The researchers gave only a description of the symptoms and the age, sex and ethnic background of the patient.
  2. "Internal dysfunction" version – The researchers added that the young man's behavior appeared irrational, was indiscriminate, persisted when the environment changed, and suggested a lack of empathy or concern for the consequences.
  3. "Environmental reaction" version – Researchers said the young man lived in a dangerous neighborhood where gang violence was common and that his behavior changed when he left that neighborhood.

The researchers then looked at the following factors and the extent to which they influenced the mental health professionals' diagnoses:

  • The clinician's age, race and gender
  • Their professional training (psychiatrist, psychologist or social worker)
  • The patient's race
  • The type of patient case history

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The Findings

Each mental health professional was asked whether he or she would agree that a young man like this one had a mental illness or psychiatric disorder. Not surprisingly, the type of case history they received influenced their answers the most. Here are the results:

  • About 70% of those given the neutral version agreed that the young man had a conduct disorder.
  • Nearly 95% of those given the "internal dysfunction" version agreed that the young man had a conduct disorder.
  • Only 35% of those given the "environmental reaction" version agreed the young man had a conduct disorder.

The second most important influence on their diagnoses was professional identity. Psychologists were twice as likely as social workers to diagnose a mental disorder; psychiatrists were nearly five times as likely.

The patient's race was the third influencing factor. Study participants were less likely to diagnose a mental disorder if the boy was labeled black or Hispanic than if the boy were described as white.

The fourth factor was age of the clinician. Older clinicians found mental disorders less often. Finally, clinicians who described their theoretical orientation as behavioral or eclectic were only about 65% as likely to diagnose a psychiatric disorder as were those who had a psychodynamic or psychoanalytic orientation.

The race and gender of the clinician (about 50% were women and about 10% minority) had no effect on these judgments, even in combination with the race of the fictional client or patient.

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Explaining the Results

The authors considered the reasons for these differences. Some, although not all, studies suggest that clinicians tend to find less mental illness in blacks than in whites with similar symptoms. Black adolescents, in particular, are more often judged to be delinquent and assigned to the juvenile justice system rather than to treatment. There is some evidence that training clinicians in the use of the American Psychiatric Association's diagnostic manual can eliminate this racial bias.

As for professional bias, psychiatrists are more familiar with the diagnostic manual and use it more often. Social workers in particular tend to focus on an individual's social context rather than psychological state. Older clinicians may have diagnosed mental disorders less often because the manual, which relies almost entirely on symptoms alone for diagnosis, was first published in 1980 after they finished their training. Also, the differences between psychodynamic and behavioral therapists, according to the authors, probably reflect both self-selection and training.

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Is Diagnosis Useless?

No. Everywhere in medicine — not just in psychiatry and other mental health fields — diagnosis is a challenge. For example, a person with pneumonia might have a fever or a cough, chest pain, shortness of breath or fatigue or any combination of those symptoms. All of those symptoms appear in other illnesses, too. Chest pain and shortness of breath could mean heart disease. Fever and cough can indicate a virus infection. Fatigue has many causes. A doctor considers all possibilities before deciding which diagnoses are possible, how to evaluate the problem further and which treatment to offer.

This study only measured a clinician's first impressions. It did not measure how diagnosis is used as a tool over time. Diagnosis is often a process, rather than a fixed or defining characteristic. Instead of saying, "You have depression or post-traumatic stress disorder," a clinician might say, "Your problems could fit into a few different categories. These categories suggest a variety of treatment approaches. Let's pick the one that makes the most sense now, but keep our minds open to revising our view as we get to know more about the problems."

That way, both clinician and client, doctor and patient continue thinking systematically about the problem. We can't avoid uncertainty. Having a list of possibile diagnoses provides a framework for choosing a reasonable treatment today and staying open to finding out what works and what doesn't tomorrow.

Professional and personal biases certainly affect first impressions. But the impression gained through careful consideration over time is much more important than the first impression.

Pottick KJ, Kirk SA, Hsieh DK, Tian X. Judging mental disorder in youths: Effects of client, clinician, and contextual differences. Journal of Consulting Clinical Psychology. Feb 2007;75(1):1-8.

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Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.


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