When labels mask oppression: implications for teaching psychiatric taxonomy to mental health counselors.

Mental health counseling programs have an ethical responsibility to teach students to think about the sociopolitical context in which behaviors become understood as symptoms of mental disorders. Elaborating on this idea, the author discusses the importance of critical thinking and of adopting a reflective comportment when mental health counselors are engaged in the process of psychiatric diagnosis. Specific suggestions for helping mental health counselors in training develop critical thinking skills and apply them to psychiatric diagnosis are identified.

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   The whole tired question of the correspondence between words and
   world stems from a simple confusion between epistemology and the
   history of art. We have taken science for
   a realist painting, imagining that it made an exact replica of
   the world. (Latour, 1999, p. 78)

   Diagnostic labels locate the causes of the problem within the
   individual; this may foreclose consideration of the societal
   context and interpersonal relations as sources of
   unhappiness. (Hare-Mustin & Marecek, 1997, p. 109)

What assumptions inform the theory and use of psychiatric taxonomy? Responding to this question requires professionals to take seriously Latour's keen observation, because it soon becomes apparent that one of the most basic assumptions is that it is both possible and desirable to try and provide an exact replica of the "world" of mental illness. That is, the field of psychopathology is grounded in the belief that mental disorders exist a priori; through empirical research, mental health professionals will be able to discover all disorders, identify their respective etiologies, and develop effective psychopharmacological interventions for each. In contrast to the positivist assumption that diagnoses accurately describe preexisting illnesses, this article is based on the position that diagnostic categories are constitutive; they construct, rather than represent, reality (Burr, 1995; Cosgrove, 2000; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995). That is, psychiatric labels create certain realities and marginalize others and in the process, may inadvertently sustain unjust social relations.

For example, Chesler (1972), Hollingshead and Redlich (1958), Horney (1973), and Szasz (1961) long ago addressed the oppressive implications of psychiatric labeling and the ways in which such labeling may reinforce gender, class, and race bias. In light of these criticisms, as well as the fact that the discipline of mental health counseling emphasizes the importance of contextualizing clients' problems (Brown & Srebalus, 2003; Seiler, 1996; Weikel & Palmo, 1996), it is not surprising that a number of scholars have suggested that mental health counselors (MHCs) be judicious in their use of psychiatric taxonomy. As Hershenson (1993) noted, "the most frequently stated underlying principle of MHC is that the uniqueness of the field among mental health professions lies in its focus on the promotion of normal, healthy development, rather than on the remediation of psychopathology" (p. 430). However, an ideological commitment to a preventive and developmental model does not negate the need for MHCs to develop knowledge of psychodiagnostics and psychiatric taxonomy. In fact, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards are clear that MHCs should be trained in psychodiagnostics (CACREP, 2001; Hansen, 1998). Thus, although the identity of MHCs is not medical, their training allows them to work effectively in agencies with a strong medical model. Especially in this era of managed care, licensed MHCs are required to use the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision ([DSM-IV-TR], APA, 2000) if they are to receive third-party reimbursement. An increasing number of MHCs are working in settings where they are routinely diagnosing clients (Fong & Sherrard, 1991; Hansen, 1998; Hohenshil, 1996; Mead, Hohenshil, & Singh, 1997). Increased familiarity and skill in using the DSM will enhance collaboration with other mental health care providers (Geroski, Rodgers, & Breen, 1997).

Hence, a critically important task is to train MHCs to use the DSM (APA, 2000) in a way that is consonant with the unique focus of the mental health counseling profession. In addition, there is a pressing need for faculty to address the issue of bias in psychiatric diagnosis, because many programs have been remiss in this area (Caplan & Cosgrove, 2004; see also Cook, Warnke, & Dupuy, 1993; Sinacore-Guinn, 1995). Although the curricula of mental health counseling programs have become increasingly rigorous and more departments are committed to preparing students to work toward social justice, the development of critical thinking remains an important area for curricula enhancement. The purpose of this article is to (a) outline some of the issues with which faculty must contend if they are to train students to use the DSM in a way that is consonant with the philosophy and focus of the mental health counseling profession, and (b) provide suggestions for MHC training programs so that MHCs will be better equipped to think critically about the sociopolitical context in which symptoms are manifest.

MOVING BEYOND CAUSAL MODELS: THE IMPORTANCE OF CRITICAL REFLECTION AND AVOIDING BIAS

In order to develop critical thinking skills and apply them to psychiatric diagnosis, it is imperative that students develop an appreciation for the epistemological commitments (i.e., claims about knowledge and truth) that ground mental health research. Many researchers start from the assumption that research hypotheses, data analyses, and diagnostic labels are neutral, objective, and free of bias. This assumption sustains the science/politics binary because it is based on the belief that science, in contrast to politics, is uncontaminated by power and particular interests (Harris, 1997). Challenging dichotomous belief systems, especially the science/politics binary, is a precondition for critical thinking and a precondition for attending to all forms of bias in psychiatric diagnosis. As Glauser (1999) pointed out, "training programs have an ethical responsibility to provide information and opportunities for counselors to confront their own cultural biases that may perpetuate racist attitudes and behavior" (p. 64). Indeed, MHC training programs provide numerous opportunities for students to confront their biases. For example, CACREP (2001) requires that all MHC programs offer courses in cross-cultural psychology.

In addition to classes that are designed specifically for students to identify and examine their cultural, ideological, and personal biases, it is also recommended that the issue of bias be incorporated in abnormal psychology and related classes. One way to encourage in-depth discussions about insidious forms of bias is to teach students that focusing predominately on causal questions about the etiology of DSM (2000) disorders over-emphasizes the role of intra-individual factors in the development of emotional distress. That is, attempts to explain a client's distress by appealing primarily or solely to intra-individual factors (e.g., cognitive distortions, neurotransmitter dysfunction, weak ego-boundaries) obscures the role of social injustice in the development of personal distress or disability (Hare-Mustin & Marecek, 1997). Faculty can discuss with students the limitations of the positivist focus on causality and concomitantly, the importance of appreciating the sociopolitical context in which symptoms are manifest. Tavris (1992) summed up the importance of attending to the sociopolitical realm when she wrote, "if a mental disorder reliably and stereotypically fits a narrow category of people, then we should be looking at what is wrong with the conditions of the people in that category, not exclusively at their individual pathologies" (p. 186). This conceptual shift, from uncritically accepting the positivist focus on causality to challenging it, helps students develop a more balanced view of diagnosis and treatment, a view that is congruent with the mental health counseling profession's developmental, preventive, and contextual approach. Also, this shift in thinking, as Tavris alluded to, fosters an appreciation for the etiological role that social injustice and violence may play in the development of emotional distress.

Another way to increase awareness of bias in mental health research is to discuss with students the history and controversies that surround many DSM (APA, 2000) diagnoses. Thinking critically about the conceptual underpinnings that inform human science research often reveals hidden class, ethnic/race, and gender biases in psychiatric taxonomy because many diagnoses reflect stereotypes. For example, Landrine (1989) demonstrated that many personality disorders listed in the DSM readily fit the stereotypes of marginalized groups such as working class minority males. Moreover, the creation of diagnoses such as Premenstrual Dysphoric Disorder (PMDD), Dependent Personality Disorder (DPD), Gender Identity Disorder (GID), and Antisocial Personality Disorder (APD) demonstrate what a psychologized society the United States has become. Healthy debate is fostered in the classroom when faculty ask students to think about the implications of medicalizing and psychologizing behavior and emotional distress.

Exposing students to the empirical research that challenges the validity and reliability of many DSM (APA, 2000) diagnoses also helps students to become more sophisticated consumers of research. Students need to know that there is little empirical support for the existence of a premenstrual mental illness, and the relevant research that provided preliminary support has been harshly criticized for having major methodological flaws (Caplan, 1995; Caplan & Cosgrove, 2004; Chrisler, 1996; Cosgrove & Riddle, 2003; Swann & Ussher, 1995; Ussher, 1992). Also, women who label their experience as Premenstrual Syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD) are significantly more likely than other women to have histories of abuse, to be in upsetting life situations, or to be in troubled marriages (Golding & Taylor, 1996, 2000; Hunter, Swann,& Ussher, 1995; Moeller, Bachmann, & Moeller, 1993; Stout & Steege, 1985). Discussing (a) how the diagnosis PMDD may inadvertently perpetuate a view of women as hormone driven and emotionally labile and (b) why the diagnosis DPD perpetuates sexist stereotypes encourages students to think critically about the costs, benefits, and sociopolitical implications of using DSM diagnoses to capture the lived experience of emotional distress. Similarly, the ability to appreciate how labels sustain heterosexist and racist beliefs is enhanced by exposing students to the controversies and criticisms surrounding the diagnoses GID and APD. Indeed, learning how to be a critical consumer of research and learning how to avoid bias when assigning diagnoses are necessary preconditions for respecting individual and cultural differences, as is consistent with CACREP (2001) standards.

CRITICAL THINKING IN ACTION: RAISING AWARENESS ABOUT CONFLICTS OF INTEREST

The DSM has been continuously revised over the last 50 years; the DSM IV was produced in 1994, and the text revision (DSM IV TR) was published in 2000. With each subsequent revision, new diagnostic categories have been added, and others sometimes changed or deleted. In addition to increasing in size, this manual has become increasingly influential, due largely to the fact that third-party reimbursement now requires a DSM diagnosis. When the process of revising the DSM is initiated, work groups and task forces are formed. The members of each work group, mainly psychiatrists although some psychologists are also members of these groups, have enormous power in deciding which diagnoses should be added to each new edition. Hence, there is the potential for conflicts of interest to arise when decisions are made about the validity of new mental disorders and about what medications should be used to treat them. The potential for conflict arises when DSM committee members are receiving funding, stocks, or honoraria from pharmaceutical companies while they are conducting research on the efficacy of psychotropic medications or when they are providing testimony to the Federal Drug Administration (FDA) about whether a new mental disorder should be included in the DSM.

Clearly, this manual has tremendous influence on people's lives. Sometimes that influence is positive. Nonetheless, a DSM diagnosis has also been used to deny health or disability insurance, and receiving a DSM diagnosis greatly increases the chance that one will be prescribed psychotropic medication (e.g., Aman, Sarphare & Barrow, 1995; Gardner, Kelleher, Pajer, & Campo, 2004). Thus, it is imperative that the committee members who are responsible for decisions about the inclusion of new DSM categories and about the efficacy of psychotropic medications are not engaged in conflicts of interest that compromise the integrity of their work. Some scientific journals have conflict of interest policies because there is the concern that such conflicts influence the outcome of research studies (Krimsky, 2003). When pharmaceutical companies fund studies, there is also a concern about publication bias. Publication bias refers to the fact that studies with positive results are likely to be published more frequently and rapidly than studies that do not show support for the pharmaceutical company's drug (Rennie, 1999). Publication bias is a serious problem because many academic researchers are asked by drug companies to sign agreements that limit what and when researchers are allowed to publish.

Although MHCs do not prescribe medications, they do work collaboratively and closely with psychiatrists. Making students aware of the association between funding source and psychotropic study outcomes prepares MHCs in training to engage more effectively with prescribing providers. Raising awareness of this association also encourages students to use critical thinking skills when evaluating published research studies. When MHC faculty raise the issue of financial relationships with pharmaceutical companies as possibly posing a conflict of interest for DSM (APA, 2000) committee members, students may grasp the potential repercussions of the "uneasy alliance" (Bodenheimer, 2000, p. 1539) between the pharmaceutical industry and clinical investigators. For example, a number of research physicians and public policy experts have raised concerns about the association between funding source and study outcome (e.g., Angell, 2000; Bodenheimer, 2000; Davidson, 1986; Friedberg, Saffran, Stinson, Nelson, & Bennett, 1999; Korn, 2000; Krimsky, 2003). With regard to drug studies published in symposium proceedings, Cho and Bero (1996) documented that "articles with drug company support are more likely than articles without drug company support to have outcomes favoring the drug of interest" (p. 485). In fact, a former editor of the New England Journal of Medicine, Angell, cautioned that academic medical centers should "[b]e wary of partnerships in which they make available their precious resources of talent and prestige to carry out research that serves primarily the interests of the companies. That is ultimately a Faustian bargain" (p. 1518).

RECOMMENDATIONS FOR MHC TRAINING PROGRAMS

Avoiding bias in psychiatric diagnosis requires critical thinking, a willingness to reflect on one's assumptions and values, and as noted above, the ability to critically evaluate mental health research. In addition to these skills, Latour's (1999) distinction between "epistemology and the history of art" (p. 78) provides a useful heuristic for avoiding bias. Following Latour, faculty can help MHCs in training to resist the temptation to take the DSM (APA, 2000) for a realist painting, imagining that it has given them an exact replica of the world of mental illness. Specifically, when teaching students about psychodiagnostics, the idea that the disorders listed in the DSM are not naturally existing entities can be reinforced. Understanding that the categories contained in the DSM are constructs will help MHCs to become more cognizant of the sociopolitical implications of using a biopsychiatric discourse.

For example, some clinicians have argued that assigning a diagnosis of Post Traumatic Stress Disorder (PTSD) fails to indict the "social contexts that produce PTSD symptoms" (Summerfield, 1995, p. 26). In other words, the diagnosis PTSD medicalizes normal responses to traumatic events and locates the problem at the level of the individual (see also Burr & Butt, 2000; Fish, 1999). As Becker (in press) noted, "although many feminist therapists have been able to use the existence of PTSD to advocate for female trauma victims, there is growing concern about the paradox of using PTSD--a diagnosis of mental disorder--to normalize women's responses to abuse" (pp. 208-209). The point is not to reject the use of psychiatric taxonomy but rather to help students to think more reflectively about the costs, benefits, and implications of assigning a diagnostic label. The following recommendations can enhance students' critical thinking skills and encourage them to be ethical mental health counselors committed to social justice.

Teach students to think critically about the political and philosophical implications of psychiatric taxonomy. Because diagnosis is not a neutral, value free scientific endeavor, students can engage in active learning by challenging conventional wisdom. Faculty can stress the importance of thinking more deeply about the conditions under which certain behaviors become understood as symptoms of mental illness. Critical thinking is stimulated by exploring the relationship between inequality and emotional distress and by questioning the therapeutic hegemony of psychological theories regarding effective coping (Fine, 1992; Hare-Mustin & Marecek, 1997; Sloan, 1997). Prilleltensky and Nelson (2002) summed up this point well:

   [diagnosing] is really quite a messy process with moral, political,
   and cultural dimensions ... [when we use diagnostic labels, we pay
   less attention to] the unique experiences, life context and
   wholeness of the individual who gets labelled. Labels can mask
   sources of oppression (p. 90).

Encourage healthy debates about diagnostic labeling. Students can be exposed to the controversies surrounding inclusion of new categories in the DSM (APA, 2000) through the wealth of literature that addresses the controversies of psychiatric labeling (e.g., Breggin, 1995; Caplan, 1995; Caplan & Cosgrove, 2004; Cushman & Guilford, 2000; Fee, 2000; Gergen, 1994; Hare-Mustin & Marecek, 1997; Kirk & Kutchins, 1992; Parker, et. al., 1995; Prilleltensky & Nelson, 2002). This literature provides a balanced view of diagnosis and encourages active learning rather than rote memorization of diagnostic criteria. Knowing the empirical research that criticizes the validity of many of the disorders listed in the DSM facilitates students' ability to take a thoughtful approach to psychiatric diagnosis.

Beware of binaries! MHCs' professional development will be aided by learning to avoid dichotomous thinking. Students and professionals do not have to make an either/or choice: either validate their clients' experiences and accept the idea that a diagnostic label reveals a real mental illness or challenge the label and undermine the legitimacy of their clients' distress. Such dichotomous thinking can be avoided by recognizing that DSM categories are constructs that reflect implicit values, beliefs, interests, and ideologies. In other words, how distress is understood and conceptualized is a function of the language/labels that are dominant in a particular culture at a particular time. Parker et al. (1995) ask a profound question in this regard:

   Might there not be some truth in the view that the delimitation of
   a psychiatric concept actually 'creates' cases which fit its
   description? One cannot say that someone is depressed or anxious
   unless these words are culturally available (that is, we have
   access to these words and know what they mean) (p. 57).

When faculty encourage students to identify their implicit assumptions and beliefs about mental illness, students are able to think more explicitly about how their beliefs are reinforced by dominant cultural representations of emotional distress.

Expose students to literature about psychotropic medications and their known and potential side effects. In order for MHCs to work effectively with prescribing providers, they need to have some knowledge about frequently prescribed psychotropic medications and their side effects. In light of the increasing numbers of children and adults prescribed antidepressants, it is important for students to be aware of the recent studies that have raised questions about an association between antidepressant use, including the use of some Selective Serotonin Reuptake Inhibitors (SSRIs), and both breast cancer (Cotterchio, Kreiger, Darlington, & Steingart, 2000; Kelly, Rosenberg, & Rao, 1998; Steingart & Cotterchio, 1995) and ovarian cancer (Harlow & Cramer, 1995). Most MHCs and prescribing providers may not be aware of the possible association between antidepressant use and cancer. The evidence of a possible association comes from two critical sources: epidemiological data (e.g., Cotterchio et al., 2000) and experimental studies finding that animals exposed to some antidepressants had accelerated growth of mammary tumors (e.g., Brandes, et. al, 1992). Although far more research is needed before any conclusions can be drawn about this association, (1) MHCs are better educated with such knowledge, and they may later be able to advocate for continued research.

Do not limit discussions of ethics to the "micro-ethics of the therapeutic relationship" (Brown, 1997, p. 51). The American Mental Health Counseling Association's ethical code (AMHCA, 2000) warns mental health clinicians of the dangers inherent in dual relationships, because conflicts of interest often arise in such situations. Usually this issue is discussed in terms of avoiding dual relationships with clients, which is what Brown referred to as micro-ethical issues. However, faculty also can usefully teach ethics by including the complex issues that may arise when DSM (APA, 2000) committee members or other academic researchers have a financial interest in findings favorable to drug companies. The results of all pharmaceutically funded research are not suspect, nor does an association between pharmaceutical companies and academic researchers necessarily imply wrongdoing (Krimsky & Rothenberg, 1998). Nonetheless, by considering the larger ethical issues involved in industry-funded drug research and encouraging healthy debate about the issue, faculty play a vital role in training students to become more sophisticated consumers of research. Specifically, when reading published studies on the efficacy of psychotropic medications, students and professionals need to be knowledgeable and careful reviewers of the methodology section, checking to see if the researchers conducted double blind studies and if they included all trials, not just ones favorable to the drug under investigation, in their meta-analytic reviews.

Incorporate material about bias in psychiatric diagnosis in the curricula of mental health counselor training programs. MHC training programs aim, responsibly, to help students learn to avoid all forms of bias. Making debiasing strategies (Spengler, Strohmer, Dixon, & Shivy, 1995) available and teaching MHCs about common clinical judgment pitfalls (Falvey, 1992; Hill & Ridley, 2001; Rabinowitz & Efron, 1997; Seligman, 1999) can be a standard part of the curriculum. MHCs in training need to know that when it comes to finding support for one's diagnostic hypotheses, what one looks for determines what one finds. Strohmer and Shivy (1994) maintain that such confirmatory biases are very robust. One useful teaching strategy is to assign articles that address the issue of bias in conjunction with specific cases from the DSM IV TR Casebook (Spitzer, Gibbon, Skodol, Williams, & First, 2002). These resources can stimulate students' discussion about implicit class, race/ethnic, gender, sexual orientation, or age bias.

For example, a powerful case study that I have used is "The Case of the Wealthy Widow" (Spitzer et al., 2002). A 72-year-old woman engages in non-stereotypical gender and age behavior; she enjoys dancing in clubs with her partner, who is a considerably younger man and with whom she is sexually active. During the diagnostic interview, she acknowledges that her behavior is not typical for someone of her age and social position. She tells the psychiatrist that she has always been conventional but wants to experience more in life, before it is too late. She is angry at her sons, who pressured her to come to the diagnostic interview, and at the psychiatrist, "insisting that they don't understand that for the first time in her life she is doing something for herself, not her father, her husband, or her children" (Spitzer, et al., p. 123). Although she has no prior psychiatric history, has no memory impairment, and is oriented in all areas, she is diagnosed with bipolar disorder. Prior to assigning this vignette, I give students all of the details contained in the case but describe the widow as a widower. Interestingly, when the client is described as a widower, my students have found nothing pathological about the male client's enjoyment of sexual activity or about his dating and spending money on a much younger woman; nor do they believe that a DSM (APA, 2000) diagnosis of bipolar disorder is warranted. This exercise provides, therefore, an opportunity for students to identify some of the ways in which their assumptions and biases affect their diagnostic hypotheses.

CONCLUSION

A major premise of this article is that mental health professionals should question, and encourage their students to question, the notion that mental disorders exist a priori, as pre-existing categories. Diagnostic language does not give one the power to identify something that really exists (i.e., that exists in the absence of a label). Assuming that diagnostic language does give one that power is problematic because it reproduces the view that emotional distress is best understood as an individual problem. In so doing, MHCs turn their attention away from the social contexts that help create the very symptoms that they are trying to treat (Burr & Butt, 2000; Fish, 1999; Summerfield, 1995). Rather than seek safety in accepted truths, MHCs must be bold and help their students to think critically. Indeed, challenging conventional wisdom through critical thinking is one of the hallmarks of the mental health counseling profession.

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FOOTNOTES

(1) It should be noted that one very recent study (Serafeim, et al., 2003) reported that three SSRIs (fluoxetine, paroxetine and citalopram) "[a]ct directly on Burkitt lymphoma (BL) cells to trigger rapid and extensive programmed cell death" (p. 3212). However, the specific conditions under which some SSRIs are more likely to be associated with the cancer cell death hypothesis as opposed to the cancer promotion hypothesis are currently not known.

Lisa Cosgrove, Ph.D., is affiliated with the University of Massachusetts Boston Graduate College of Education. E-mail: [e-mail].