Correspondence between level of racial identity of African-American therapists and of a vignette-depicted African-American client and assessed client problem severity

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CORRESPONDENCE BETWEEN LEVEL OF RACIAL IDENTITY OF AFRICAN-
AMERICAN THERAPISTS AND OF A VIGNETTE-DEPICTED AFRICAN-
AMERICAN CLIENT AND
ASSESSED CLIENT PROBLEM SEVERITY

by

Saul Thomas Bush
____________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
EDUCATION (COUNSELING PSYCHOLOGY)

December 2008

Copyright 2008 Saul Thomas Bush

ii
DEDICATION

This manuscript is dedicated to:

My mother, Judith Hannah, for her continued support and strength in my life

My wife, Michelle Avril Bush, for being my partner in all that I do

My son, Khalil Avril Bush, for his kisses, hugs, and cuddles throughout this project

My soon to be born son Jaylen for promises for the future

iii
ACKNOWLEDGMENTS

Special gratitude is extended to:

Rodney Goodyear, Ph.D. for his direction, expertise, dedication, and patience

Gerald Stone, Ph.D. and Gerald Davidson, Ph.D. for their invaluable contribution to this
project and guidance throughout

Pamela Ashe, Ph.D., Chris Bresnahan, Ph.D., Romel Khalaf, B.A., and Mark Hamilton,
B.A. for their knowledge, moral support, technical assistance, and guidance on this
journey

iv
Table of Contents

DEDICATION ................................................................................................................ii
ACKNOWLEDGMENTS ............................................................................................. iii
List of Tables..................................................................................................................vi
List of Figures ...............................................................................................................vii
CHAPTER 1: CONCEPTUAL AND EMPIRICAL FOUNDATION FOR THE
STUDY ...........................................................................................................................1
Clinical Decision Making ............................................................................................2
Racial Identity Development........................................................................................5
Ethnic and Racial Identity........................................................................................6
Black Racial/Ethnic Identity and Perceptions ...........................................................7
Black Racial/Ethnic Identity in Counseling ............................................................16
Research Questions....................................................................................................19
CHAPTER 2: METHODS.............................................................................................21
Participants................................................................................................................21
Dependent Variables..................................................................................................22
Global Assessment of Functioning. ........................................................................22
DSM Axis I Diagnosis ...........................................................................................24
Independent Variables ...............................................................................................24
Revised Cross Racial Identity Scale (CRIS) ...........................................................24
Manipulation of Racial Identity of Client ...............................................................27
Vignette Development ...........................................................................................29
Procedure ..................................................................................................................30
Recruitment of Participants....................................................................................30
CHAPTER 3: RESULTS...............................................................................................32
Descriptive Statistics..................................................................................................32
Research Questions....................................................................................................36
Research Question 1 ..............................................................................................36
Research Question 2 ..............................................................................................37
Research Question 3 ..............................................................................................38
Research Question 4 ..............................................................................................38
Summary ...................................................................................................................39
CHAPTER 4: DISCUSSION.........................................................................................41
Discussion of the Findings.........................................................................................41
Race as a Factor.....................................................................................................43
Results Related to the Research Questions .............................................................43
Limitations ................................................................................................................45

v
Recommendations for Future Research......................................................................46
Summary ...................................................................................................................48
REFERENCES..............................................................................................................49
APPENDIX A: Vignettes Used in the Study..................................................................54

vi
List of Tables

Table 1. Client GAF Scores by Racial Identity of Client and Mental Health
Professional...................................................................................................................33

Table 2. Client Diagnosis by Racial Identity of Client and Mental Health
Professional...................................................................................................................34

vii
List of Figures

Figure 1. Mean GAF scores assigned the client depicted at each level of racial
identity ..........................................................................................................................36

Figure 2. Mean GAF scores by Client and Therapist levels of racial identity..................39

viii
Abstract

This was the first study to examine the relationship between racial identity status of both
clinicians and a client depicted in a vignette and the diagnostic impressions of those
clinicians. Participants were 89 African American mental health professionals (53 female,
36 male). They were randomly assigned to read one of three versions of a vignette
describing an African American woman with a mood disorder. In each version, though,
descriptors were chosen to signal one of three levels of racial identity: Pre-encounter,
Immersion-Emersion, and Integrated. They then were asked to (a) assess that client’s
level of functioning using the /DSM-IV/ Global Assessment of Functioning Axis V Scale
(GAF) and (b) provide an Axis I diagnosis. They also completed the Revised
Cross Racial Identity Scale (CRIS), which then was used to assign them to one of three
levels of racial identity: Pre-encounter, Immersion-Emersion, and Internalized.
Because 71% of the participants were in the Internalized stage of racial identity, there
were insufficient cell sizes to examine interaction effects. However, main effects were
examined for racial identity levels of the clinicians and of the client. Significant between-
group differences were obtained for client racial identity levels, with a near-linear trend
whereby GAF scores for the Pre-encounter client were lowest, with successively higher
scores for the Immersion/Emersion and the Integrated client, in turn. No other differences
were found.
That both the clinicians and the depicted client were African American minimized race as
a factor in clinician judgment and highlighted the prominence of racial identity level.
Whereas the study originally had been framed as one of assessment bias, the alternate

ix
explanation is that the stages of racial identity levels are proxies for general level of
functioning. If so, the obtained between-group differences would reflect actual
differences in client functioning rather than bias.

1
CHAPTER 1:
CONCEPTUAL AND EMPIRICAL FOUNDATION FOR THE STUDY

Whereas we experience our identities subjectively, we express them through
behaviors and attitudes that elicit complementary responses from others (Markey, Funder,
& Ozer, 2003; Tracey, Ryan, & Jaschik-Herman, 2001). Moreover, identity has a number
of determinants that each has particular effects on its expression.
One such determinant, or aspect, of identity derives from our racial or ethnic
group membership (Helms, 1990; Root, 1998; Ruiz, 1990). Many investigations have
examined how racial identity affects how others see us and how we, in turn, see them.
These interpersonal dynamics are presumed not only to operate in everyday life, but also
to affect therapy processes and outcomes (Baker & Bell, 1999; Parham & Helms, 1981).
However, the racial identity status of the clinician or of the client might affect behavior
and judgment is completely overlooked in this literature.
The present study was intended to address that gap in the literature. Specifically,
it examined whether racial identity status of African-American mental health
professionals and of an African-American client depicted in a vignette, would
independently or in interaction affect the clinicians’ diagnostic impressions of that client.
To develop the argument and establish the foundation for the study, this chapter
will focus, in turn, on clinical judgment/decision-making including known and
documented threats to clinical decision-making, general, racial, and ethnic identity and
their influences on the aforementioned area.

2
The discussion will not include extensive discussion on the theoretical notions of
the “self” as it is a concept outside of the scope of the present work.
Clinical Decision Making
Psychological tests outperform clinicians’ classification and predictive abilities
(Miller, 2001). However, clinicians rarely use actuarial approaches; certainly, they do so
less often than the research indicates as appropriate best-practice behavior. Clinicians
tend instead to rely on their own impressions and their synthesis of client data available
to them. To the extent this is so, their judgments are the critical factor in client
assessment (Garb, 1998).
In his review of empirical studies of clinical judgment and decision-making, Garb
(1998) observed that clinical judgment and decision-making has not garnered the
attention it deserves. The importance of this was underscored by Dawes (1994), who
offered well-buttressed criticism that mental health practitioners make an inordinate
percentage of unreliable and invalid judgments.
Bias, or the tendency to filter client information through a lens of preconceptions
about clients of a particular “type,” is a particularly important factor that can affect the
accuracy of assessment. Garb (1998) included a number of sources of potential bias,
including those related to gender, social class, and race or ethnicity.
In perhaps the most famous study of potential gender bias, Broverman,
Broverman, Clarkson, Rosencrantz, and Vogel (1970) concluded that mental health
practitioners operated from a bias against women in that they equated mental health with
someone who was depicted as having stereotypic male traits, but not with someone
depicted has having stereotypic female traits. However, when subsequent studies, such as

3
that of Widiger and Settle (1987), corrected methodological problems in the Broverman
et al. study, they were unable to replicate the results. In fact, Garb (1998) concluded that
evidence for the gender bias, was scant. Studies that have indicated that gender bias
contaminates clinical judgment have gone largely unreplicated.
Studies of socioeconomic status (SES) based bias have had a similar history of a
single, high profile study that elicited professional and research attention. Hollingshead
and Redlich (1958) concluded that lower SES psychiatric patients were more likely to be
diagnosed as schizophrenic. In the intervening years, of course, diagnostic tools such as
the American Psychiatric Association’s Diagnostic and Statistical Manual, have added
more objective criteria and therefore greater reliability, presumably countering a great
deal of SES and other bias. Therefore, even though Kales (2000) concluded that SES
remains a factor in the diagnosis of major psychiatric disorders, Garb (1998) concluded
that the literature does not support this.
With respect to potential bias based on clients’ racial and ethnic group
membership, it is important to begin with the acknowledgement that there are real
between-group differences in prevalence rates for various disorders (Lopez, 2003; U.S.
Department of Health and Human Services, 2001). As a result, it is possible that bias
might manifest either over diagnosing or under diagnosing mental disorders. These biases
are important issues with respect to stigma and quality of care. However, they also affect
service utilization, for even the perception that there is bias can affect when and how
minorities seek services. In a metaanalytic study, Whaley (2001) demonstrated that
cultural mistrust among African Americans is a factor that reduces the likelihood they
will seek treatment.

4
Garb (1998) similarly had concluded that race bias relating to African-American,
Mexican-American, and White clients generally has not been shown to be a significant
source of diagnostic variability when considering either children or adults. However, in
the area of violence prediction of psychiatric inpatients Garb (1998) noted that African-
American patients were predicted to be more violent than White psychiatric inpatients,
even in the circumstances in which race was not related to violence. The findings have
continued to be replicated. Lopez (1989) had noted that clinicians significantly
overpathologize psychotic symptoms of ethnic minorities while under-diagnosing mood
and anxiety related symptoms. Hispanic and African-American clients have been shown
to be over diagnosed with schizophrenia and under diagnosed with mood disorders
compared to their White counterparts (Adebimpe, 1981; Rosenthal & Bervin, 1999).
Whaley (1998) suggested that perceptions based on unexamined stereotypes often have a
negative impact on the diagnostic process. Moreover, although it is often believed that
psychiatric disorders manifest in universal ways, some ethnicities have been observed to
experience and/or express psychopathology in alternative manners (Whaley, 1997).
Many factors can confound and distort mental health clinicians’ diagnostic
judgment. Biases concerning race and ethnicity are one of those factors. However, an
examination of how stages of racial identity (of the clinicians; of the client) may
moderate those biases has been nearly completely missing in the literature has been. To
understand why this might be a factor and how, it first is necessary to understand racial
identity models. This is the focus of the material that follows.

5
Racial Identity Development
It is well-documented that racial identity development corresponds with enhanced
self-esteem (Cross & Fhagen-Smith, 1995; Harter, 1990; Helms, 1990; Nghe & Mahalik,
2001). This is true of members of ethnic and racial minority groups who find shelter
through racial identity from an oppressive environment in a strong alliance with their
particular group (Cross, 1991) as well as adolescents who find some peace from teen-
awkwardness in strong identification with a particular crowd (Harter, 1990). Theorists
(Cross, 1991) often view ethnic and racial identity development as defense against
deleterious forces within groups in which the individual does not identify.
Phinney (1990) clustered ethnic identity models into three broad types. The first is
that of social identity theory. This theory strives to confront the myriad of responses that
stigmatized group members may invoke to enhance their individual and group positions.
Social identity theory is the dominant one in the literature focusing on identity
development for ethnic minorities (Allen, 2001). The theory posits that people attempt to
maintain or improve their self-esteem and work toward a positive self-concept and that
group membership elicits a feeling of worth that leads to a healthy self-concept. This
theory involves two qualitatively different aspects of identity: (a) the group identity
(illustrating characteristics that define one's group but may not be sufficient in defining
the individual), and (b) the personal identity (personal characteristics; i.e., cognitive
processes, happiness or worry, etc.).
Acculturation is the second of Phinney’s ethnic identity model’s categories. This
process refers to the changes in attitudes, behaviors, and values a group or individual
goes through to be more similar to the dominant group. The process of acculturation

6
requires a separate and distinct culture from which to acculturate and therefore applies
poorly to African Americans.
The third category concerns ethnic identity, viewed as a lengthy process, and
decisions made by individuals with regard to the meaning their ethnicity has for them is
believed to be of significant importance. The following section will elaborate on the
models that fit under this framework.
Ethnic and Racial Identity
There now is a substantial literature to document the influence of racial or ethnic
identity development on individual functioning in an array of areas. These areas include
general adolescent development (Aries & Moorehead, 1989; Bennion & Adams, 1986),
specific racial/ethnic contexts (Helms, 1990), and mental health and counseling (Helms,
1984; Helms & Cook, 1999; Neville, Heppner, & Wang, 1997; Neville & Lilly, 2000).
The terms racial identity and ethnic identity have been used synonymously, even
though race and ethnicity typically have not. According to Helms (1990), ethnicity
should be viewed as a group classification that describes individuals sharing unique
cultural and social features (e.g., religion, language, etc.) which are passed down through
generations. Race refers to anthropological categories developed to classify human
beings primarily by phenotypic criteria. Because ethnicity is not biologically defined,
race and ethnicity are not synonymous.
Helms (1996) asserted that a model should be considered one of racial identity if
what are described are individual or group reactions to societal dynamics of racial
oppression, but it should be considered one of ethnic identity if it focuses on the
attainment and/or maintenance of cultural characteristics. Although this distinction is

7
potentially valuable to researchers, the literature itself remains ambiguous. Much of what
Helms (1996) consided ethnic identity corresponds to Phinney’s (1990) conceptualization
of acculturation. Further studies have discussed ethnic identity as a portion of
acculturation and have suggested that Blacks in America do not typically undergo
acculturation because they are not acculturating from a distinctly separate culture placing
the terminology in yet another precarious position.
Helms (1990) observed that individuals mistakenly use a person’s racial
categorization (e.g., Black versus White) to denote racial identity; the latter term more
accurately refers to a sense of collective identity, based on one’s perception that he or she
shares a common racial heritage with a particular racial group. Helms suggested that
racial identity development theory involves psychological phenomena as well; that is,
belief systems adapting to accommodate perceived differences of experience on the basis
of racial-group membership.
According to Helms (1990), many major racial identity models (regarding Black
and White people), in general, refer to whether a Black or White person chooses to
identify with the racial group that he or she is generally assumed to share racial heritage.
Many models refer to the quality or manner of one’s identification with the respective
racial groups.
Black Racial/Ethnic Identity and Perceptions
Research conducted during the late 1930s and through the 1940s (Clark & Clark,
1947) suggested that Black Americans were consumed with self-hate and consequently
had lower self-esteem than their White counterparts. Studies included doll preference of
Black and White children (Clark & Clark). The Black children showed less preference as

8
to whether to play with a Black doll vs. a white doll and were assumed, therefore, to have
lower self-esteem. This idea of “reflective appraisal” dominated the literature for some
time. In part, this was because self-esteem was not directly measured.
However, in the late 1960s, measures that directly examined self-esteem were
developed and the obtained data often were surprising in light of the prevailing believes.
Black children, for example, were found to have higher self-esteem than their White
counterparts (Rosenberg & Simmons, 1972).
During the Civil Rights Movement and particularly the Black Power movement of
the 1960s and 1970s, Blacks demanded recognition. On a massive scale, this assertion
and leadership of the Black community was a powerfully unnerving experience for many
Whites and assimilated Blacks of the time (Helms, 1990). The theories then constructed
were driven by an underlying philosophy equating Black assertion with hostility,
characterized by rioting, destruction of property and assault. This led many social
scientists to see African Americans as unpredictable and unstable in both society in
general and in the counseling process specifically (Helms). Much of the literature of the
era in this domain played on what was termed by Helms to be “White fears.” The theories
suggested that Blacks would act out their anger and frustration with Whites through
passivity, mistrust, and/or overt hostility (Helms). The models developed lacked the
notion of a positive and healthy development of Black racial identity in spite of the
overall oppression experienced by Blacks. Instead, much of the literature was aimed to
help therapists (mostly white) to deal with the Black client’s intrapersonal and
interpersonal dynamics (Helms).

9
In response, theories and models for Black identity development began to appear
in psychology literature. That literature generally can be identified as adhering to one of
two major theoretical conceptualizations. The first, Helms (1990) calls “Black client” (or
person as-problem). The second perspective is generally referred to as “Nigrescence”
(French, for becoming Black). Due to the differences in the underlying perspectives, they
have had different influences on the literature.
In general, the client-as-problem models suggested that by looking at the
differences in the overt behaviors of Blacks, counselors could determine which clients
would pose most problems for which race of therapists. Vontress’ (1971) typology is one
of the most widely discussed and the most influential of the client-as-problem models.
His model illustrated three types of Black people: “Blacks,” “Negroes,” and “Coloreds.”
Vontress theorized that the identities were differentiated by the Black person’s interracial
thoughts, interracial feelings, and behaviors.
He asserted that “Blacks” would be people who value African physical features,
have a sense of the historical struggles of Black people in the Western-World context,
and would be intolerant of Whites who interact with Blacks from the vantage point of
racism. He described “Negroes” as integrationists who are willing to accommodate
Whites who do not display racist behaviors or opinions. He saw “Coloreds” as Blacks
who appraise and identify themselves the way that Whites do.
Vontress (1971) asserted that Negroes would be most willing to participate in
psychotherapy, Coloreds would appear to be willing to participate, and Blacks would be
least willing to participate. Assuming psychotherapy is viewed as a healthy endeavor for
individuals to undertake promoting psychological health, Vontress’ typology may lead

10
one to view Black clients who present with a heightened connection with and
understanding of their racial and ethnic group’s plight as potentially less healthy. In other
words, the more salient one’s Black racial/ethnic identity the less psychologically healthy
the individual is assumed to be or become. However, if viewed from a neutral stance, the
value of this perspective is its presentation of multiple Black identities; the typology
challenged the notion that Black people of the era were a homogeneous group with one
healthy identity possible, assimilation. Specifically:
1. Coloreds (African Americans who perceive and evaluate themselves
according to White standards)
2. Negroes (African Americans who are uncertain of how they feel about
themselves, Blacks, or Whites)
3. Blacks (African Americans who are not ashamed of African racial features,
and resist affronts to human dignity)
In contrast to this model of categories, the Nigrescence models characterized
Black identity development as being stage related: Nigrescence is a developmental
process by which a person becomes Black (Helms, 1990). According to Helms, the
Nigrescence or Black Racial Identity models aimed to separate aspects of Black identity
development that occurred primarily in response to racial oppression (e.g., some forms of
ascribed identities and reference-group orientations) from those aspects (e.g., personal
identity) that occurred as a normal part of the human self-actualization process.
One of the most influential of the Nigrescence models is that of Cross, who
introduced it in 1971 and then revised it in 1991. His model focused on the development
of identity within the context of social oppression, and it assumes that if social

11
circumstances are supportive, then people can assume a healthy self-esteem and a strong
sense of cultural affirmation. If these circumstances are overrun by the dynamics of
oppression and discrimination, then the Nigrescence stages are likely to reflect the
individual’s path to identity. Due to the model’s popularity, it can be speculated here that
Cross and his colleagues viewed the social environment of the United States to be
exemplary of the latter.
The stages that characterized the identity development process in Cross’ (1971)
original Nigrescence model are:
1. Pre-Encounter. Black individuals whose identity is based on mainstream
values; Pro-White Anti-Black; Self-hating resulting in low self-esteem,
impaired personality, and poor mental health functioning.
2. Encounter. Black individuals experience single or multiple “eye-opening”
events that lead them to question their beliefs about the role of race in
American society.
3. Immersion-Emersion. At the beginning of the stage, Black individuals
immerse themselves in Black culture to the point of romanticizing it, along
with almost all facets of life; “everything Black is good;” strong anti-White
identity adopted; “all whites are evil.” During the second half of the stage,
another reevaluation process begins with Emersion where individuals become
emotionally calmer and rationally examine their experiences and racial
identity and they begin to abandon the anti-white sentiment and move to the
next stage.

12
4. Internalization. Intellectual and emotional acceptance of being Black; Black is
background of individual’s existence; other aspects of identity are considered
as important as race.
5. Internalization-Commitment. Black self-acceptance moves to activism;
involvement in social change and civil rights issues. (People at the
internalization stages are considered to be psychologically healthy).
In the revised version of the Cross (1991) Nigrescence Model, identity has two
components: (1) a general personality or personal identity (“my personality” / traits,
psychological processes, cognitive skills, worry or happiness, etc.), and (2) a reference
group orientation or social identity component (used by person to make sense of oneself
as a social being / “what it means to be Black or Heterosexual, etc.”). In the Nigrescence
model, group identity (Black identity) is never defined by using personal identity
variables. Cross asserted that these variables tell us nothing of the person’s racial-cultural
frame of reference.
The Social Identity component can be conceptualized as a multidimensional
matrix. The more cells in the matrix that are connected, the more multicultural the
individual would be (e.g., the person can be a homosexual male, Catholic, auto
mechanic). According to Nigrescence theory, it is imperative to look at how a person
thinks about, feels, and acts in reference to one cell or a subset of cells in a person’s
(reference group orientation) matrix.
One criticism of the original Cross Nigrescence model is that it appears to give a
rather bleak notion of Black identity development. The assumption is that one cannot
experience a healthy sense of Blackness without first experiencing the pain of White and

13
Self-hate (moving from Black self-hatred to Black self-acceptance). This reflects, in part,
historical context in which the model was developed. It was originally designed for
insight into the identity development of Blacks involved in the Black Power Movement,
and it assumed that because underrepresented peoples must fight for legitimacy and self-
affirmation, there would be instances of undeserved harm and pain.
The revised model (Cross, 1991) takes into account the notion that there is a
universe of identity types. The model is designed to identify those who would and/or do
engage themselves in problems faced by the overall Black community and those who
would or do not.
1. Pre-Encounter Assimilation. Social identity is organized around his/her sense
of being an American and an individual. Little significance is accorded racial
group identity; Anti-Black and multiculturalism.
2. Pre-Encounter Miseducation. Blacks who accept as truth, stereotypical
accounts of Black people; will separate the negative Black stereotypes in such
a way so they do not interfere with their own personal self-image.
3. Pre-Encounter Self-Hatred. Self-hatred because they are Black.
4. Encounter. This stage is identical to that of the original model.
5. Immersion-Emersion Anti-White. Consumed by hatred of all things considered
White; full of fury and pent-up rage.
6. Immersion-Emersion Intense Black Involvement. Romanticizes all things
Black; evidence dichotomous mentality about complex issues.

14
7. Internalization Nationalist. Person stresses an Afrocentric perspective about
oneself, Black people and the surrounding world; definitely engages Black
problems.
8. Internalization Biculturalist. Comfortable fusion of White and Black cultures;
engages Black issues while openly engaging aspects of mainstream culture.
9. Internalization Multiculturalist. Nearly equal weight is given to multiple
categories that drive the person’s sense of identity.
Nigrescence theory continues to exhibit great usefulness in the study of African-
American identity development and its usefulness continues to be exhibited through
recent investigations (Pierre & Mahalik, 2005; Plummer, 1995). Recently, Want, Parham,
Baker, and Sherman (2004) investigated Black student ratings of Black and Caucasian
counselors who varied in their levels of racial consciousness, “a multidimensional
construct that includes a counselor’s awareness of self as a racial being, awareness of the
racially different client, and awareness of how the interaction of these two variables
might affect the therapeutic relationship” (p. 126). Students completed The Racial
Identity Attitude Scale (Short Form; RIAS-B; Parham & Helm, 1981) a scale designed to
assess attitudes identified in Cross’s model.
Want et al. (2004) found that Black college students preferred Black counselors
with high racial consciousness. Their results appeared to confirm Cross’s earlier findings
regarding Black racial identity. For instance, strong Pre-encounter attitudes held by
participants correlated to low ratings of the African-American counselor with high racial
consciousness. In addition, Encounter attitudes correlated to lower favorability ratings of
White counselors, Immersion/Emmersion attitudes reflected similar findings.

15
Acknowledging one of the limitations of Nigrescence theory, Parham (1989)
noted that studies using the theory have been conducted primarily with college students
as participants. He discussed Nigrescence as continuing through the life span and
proposed that Nigrescence occurs in three phases of adulthood.
1. Late Adolescence/Early Adulthood. Characterized by activism and an
emphasis on the overt behavioral manifestations of “Blackness” (one’s choice
of friends or books).
2. Middle Adulthood. Focused on institutional issues as more opportunities and
responsibilities are available (racial composition of the organizations a person
joins).
3. Late Adulthood. African Americans reflect on their role and contributions to
society (racial identity is reflected in the ways that they consider their role as
a Black person).
Parham also noted three alternative pathways to racial identity development. Stagnation
is believed to be occurring when individuals remain in one particular stage throughout
life; Linear Progression suggests one is moving from one stage to the next in the
proposed manner over the life span; and, Recycling describes the process of Blacks
whom are characterized in the internalized stage and may experience additional
encounter experiences that force the individuals to rethink their identity and recycle to an
earlier stage (although there is little likelihood that they will return to the pre-encounter
stage).
Helms (1990) also introduced alternative views of nigrescence and proposed that
the process is less linear and stepwise but more fluid. She asserted that components of all

16
stages are typically present in differing degrees at every stage. The stages are more
descriptive of the overall experience.
In addition, there are African centered models focusing on African self-
consciousness, such as Baldwin’s (1985) collective consciousness theory, and achieved
identity models of Phinney (1990), although not exclusive to any racial or ethnic group.
As well, there are multidimensional models that focus on multiple dimensions of identity
(e.g., closeness, Black separatism, Black Group evaluation) in measuring racial identity.
Perceptions and prejudgments as functions of perceived racial/ethnic identity
organization have been well documented in the literature. Nghe and Mahalik (2001)
found that Cross’s (1991) stages of Nigrescence were effective in predicting what types
of psychological defenses individuals use. Specifically, individuals used the most mature
defenses in the internalization stages whereas participants in the other stages used the less
mature and less healthy defenses more often. Gurung and Mehta (2001), too, found that
racial identity status predicted personal characteristics. In this case, they found that the
more assimilated mental health professionals were, the less effective they believed
themselves to be in regards to treating ethnic minority clients.
Black Racial/Ethnic Identity in Counseling
Black racial/ethnic identity has played a role in the development of theory
regarding client-clinician matching. Although racial similarity itself has not been found to
be useful in predicting counseling processes and outcomes (Shin et al., 2005) there is
evidence that clients prefer counselors of similar racial or ethnic backgrounds (Atkinson
& Lowe, 1995). In fact, the received wisdom in counseling centers and other venues for

17
psychotherapy used to be that clients of a particular ethnicity or race should be matched
with a counselor of the same ethnicity or race.
In an early challenge to this position, Parham and Helms (1981) argued that stages
of racial/ethnic identity development should be considered. They found that stages of
racial/ethnic development were potential predictors of whether Black college students
prefer a White or Black therapist. Atkinson et al. (1995) argued that the role of racial and
ethnic identity is crucial to client satisfaction, for clients look to non-verbal cues and
related methods of communication to determine the credibility of the counselor; these
methods are often mired in the structure of racial/ethnic identity.
Helms (1990) provided a framework to suggest how the therapist and client’s
stages of racial/ethnic identity (specifically focusing on Blacks and Whites) interact and
influence the working alliance. She identified four possible client/therapist relationship
types. The first relationship type is parallel, which exists when both the client and
therapist share the same racial attitudes about Blacks and Whites. The second relationship
type is crossed. In contrast to a parallel relationship, a crossed relationship exists when
the racial attitudes held by the client and therapist regarding Blacks and Whites are
contradictory. The third relationship type, progressive, is said to exist if the counselor’s
stage of racial identity development is at least one stage above that of the client. Last, the
fourth relationship type, regressive, is one in which the client is at least one stage more
advanced than the therapist. Helms (1990) suggested that whereas a progressive
relationship can possibly be helpful to a client, a regressive relationship would likely end
in termination.

18
Another major matching variable concerns beliefs that people hold regarding the
causes of psychological problem and distress. Ethnic and cultural differences are likely to
influence differences in beliefs of etiology of these problems (Hahn, 1995), as would
racial identity level. Not only are beliefs regarding the cause of psychological distress
important matching variables but so too are the beliefs about the cures of these problems.
It is critical for clinicians to consider the importance of a client’s beliefs about the
etiology of their distress and to make efforts to use this information when selecting a
treatment plan (Wampold, 2002).
Black racial identity and clinical assessment studies have focused on racial
identity of therapist and client as moderators of most processes and outcome. Research
that has focused on how clinicians’ diagnostic impressions of clients may be affected by
racial factors has been relatively scant. An analogue study by Loring and Powell (1988)
examined how race and gender affected the diagnostic judgments of Black and White
psychiatrists, but racial identity level was not a factor. Ladany, Inman, Constantine, and
Hofheinz (1997) found that racial identity levels affected clinicians’ levels of integrative
complexity in case formulations related to African American female clients. However,
none has examined directly the effects of race and racial identity levels of clinicians.
Helms (1986) suggested that due to the intricate nature of the relationship
between one’s racial identity and one’s worldview, personality, and race, racial identity
status should have a direct influence on both the psychotherapeutic process and client
assessment.

19
Research Questions
This study focused specifically on Black clinicians from the professions of
psychology, social work, and marriage and family therapy. This inclusive strategy was
based on the assumption that in our modern health care system, all clinicians are forced to
render DSM diagnoses and so there is no reason to believe that their diagnostic
judgments would differ systematically from one another.
The main objectives of the current, analogue study were to determine whether a
client’s racial identity and that of a therapist would affect the severity of a therapist’s
diagnosis. The following research questions guided the study:
1. Will the level of racial identity of an African-American client depicted in a
vignette affect the level of functioning African-American mental health
professionals will perceive that client to have?
2. Will level of racial identity of African-American mental health professionals affect
the level of functioning they ascribe to an African-American client depicted in a
vignette?
3. Will the level of racial identity of an African-American client depicted in a
vignette interact with the level of racial identity of African-American mental
health professionals in predicting the level of functioning they ascribe to that
client?
4. Will the level of racial identity of an African-American client depicted in a
vignette affect the Axis I diagnosis African American mental health professionals
will perceive that client to have?

20
5. Will level of racial identity of African-American mental health professionals affect
the Axis I diagnosis they ascribe to an African-American client depicted in a
vignette?
6. Will the level of racial identity of an African-American client depicted in a
vignette interact with the level of racial identity of African American mental
health professionals in predicting the Axis I diagnosis they ascribe to that client?

21
CHAPTER 2
METHODS

This chapter describes the methods used to address the study’s research questions.
Specifically, it describes the participants, measures, and procedures.
Participants
Participants were 89 (53 female; 36 male) mental health professionals with a
mean age of 39.45 (SD = 8.71), all of whom were African-American. They reported a
mean of 7.83 years of practice (SD = 6.09).
Slightly more than half (N = 46; 51.7%) had earned doctorates. The remainder
reported having an MFT (N = 31; 34.8%), MSW (N = 10; 11.2%), or an unspecified
masters (N = 2; 2.2%). Forty-two did not report having a license; those who did report a
license reported having it as a psychologist (N = 25; 53.19%), a marital and family
therapist (N = 20; 42.55%), or a social worker (N =2; 4.26%).
Most identified as African American (N = 54; 60%), with the remainder
identifying as Black (N = 23; 25.8%), African (N = 3; 3.3%), West Indian/Caribbean
Black (N = 2; 2.2%), Mixed (N = 2; 2.2%), or Other (N = 5; 5.6%).
All participants reported being trained in the use of the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition. As well, they reported regular practice of the
DSM IV ontology in their work.

22
Dependent Variables
Two dependent variables were used in this study. One concerned the participants’
perceptions of the client’s global levels of functioning, the other concerned the
participants’ perceptions of the client’s Axis I diagnosis.
Global Assessment of Functioning.
The DSM-IV (1994) Global Assessment of Functioning Scale provides an overall
assessment of how well the clinician perceives the client to be functioning
psychologically, socially, and occupationally. GAF scores range from 0-100, with the
scoring rubric as follows:
91-100. Superior functioning in a wide range of activities, life's problems never seem
to get out of hand, is sought out by others because of his or her many qualities.
No symptoms.
81-90. Absent or minimal symptoms, good functioning in all areas, interested and
involved in a wide range of activities, socially effective, generally satisfied
with life, no more than everyday problems or concerns.
71-80. If symptoms are present they are transient and expectable reactions to
psychosocial stresses; no more than slight impairment in social, occupational,
or school functioning.
61-70. Some mild symptoms OR some difficulty in social, occupational, or school
functioning, but generally functioning pretty well, has some meaningful
interpersonal relationships.
51-60. Moderate symptoms OR any moderate difficulty in social, occupational, or
school functioning.

23
41-50. Serious symptoms OR any serious impairment in social, occupational, or
school functioning.
31-40. Some impairment in reality testing or communication OR major impairment in
several areas, such as work or school, family relations, judgment, thinking, or
mood.
21-30. Behavior is considerably influenced by delusions or hallucinations OR serious
impairment in communications or judgment OR inability to function in all
areas.
11-20. Some danger of hurting self or others OR occasionally fails to maintain
minimal personal hygiene OR gross impairment in communication.
1-10. Persistent danger of severely hurting self or others OR persistent inability to
maintain minimum personal hygiene OR serious suicidal act with clear
expectation of death.
0. Not enough information available to provide GAF.
In a study assessing the reliability and validity of the Global Assessment of
Functioning (GAF) Scale, Hilsenroth et al. (2000) demonstrated that the scale had high
inter-rater reliability. The intraclass correlation for the one-way random effects model test
was .86 (a correlation above .74 is considered excellent) (Hilsenroth et al.). The
Spearman-Brown interrater reliability .92.
As predicted, the GAF Scale was significantly correlated with the SCL-90-R
Global Severity Index, a self-report measure of psychiatric symptoms (Hilsenroth et al.,
2000), thus indicating evidence for the convergent validity of the scale. As predicted, the
GAF Scale was not significantly correlated to two other measures, a measure of social

24
impairment (the Social Adjustment Scale) and a measure of interpersonal impairment
(the Social Adjustment Scale global score), thus indicating discriminant validity of the
measure (Hilsenroth, et al.).
DSM Axis I Diagnosis
The second dependent variable in this study was the clinicians’ perceptions of the
more appropriate Axis I diagnosis. Participants provided these as open-ended responses.
Because of the variability with which they were written, the researcher assigned each
diagnosis to what seemed the most appropriate category by coding the diagnoses into
DSM IV categories. Specifically, each response was coded as primarily related to mood
disorder, adjustment disorder, impulse control disorder, psychotic disorder, or no
diagnosis (recognizing that not all these categories would fit within the DSM’s Axis 1
rubric).
Independent Variables
The (a) therapists and (b) clients were blocked according to racial identity levels.
Assignment of therapists to level of racial identity was made using their scores on the
Revised Cross Racial Identity Scale (Vandiver, Cross, Worrell, & Fhagen-Smith, 2002).
Client racial identity level was manipulated by the wording ofthe vignette that described
the client.
Revised Cross Racial Identity Scale (CRIS)
The CRIS is a 40-item inventory designed to assess six of the eight Cross (1991,
1995) levels of African American racial identities. Each of its subscales measures one of
six stages of Black identity development:

25
1. Pre-Encounter Assimilation (PA). “I think of myself primarily as an
American, and seldom as a member of a racial group.”
2. Pre-Encounter Miseducation (PM). “Too many Blacks “glamorize” the drug
trade and fail to see opportunities that don’t involve crime.”
3. Pre-Encounter Self Hatred (PSH). “I go through periods when I am down on
myself because I am Black.”
4. Immersion-Emersion Anti-White (IEAW). “I hate the White community and all
that it represents.”
5. Internalization Afrocentricity (IA). “I see and think about things from an
Afrocentric perspective.”
6. Internalization Multiculturalist Inclusive (IMCI). “As a multiculturalist, I am
connected to many groups (Hispanics, Asian-Americans, Whites, Jews, gays
& lesbians, etc.”
Of the 40 items, five belong to each of the six stages; the remaining 10 are filler
items. Participants respond to the items via a 7-point Likert scale which ranges from
“strongly agree” to “strongly disagree.” Scores for each subscale range from 5 to 35, with
higher scores indicating greater endorsement of stage reflected by the particular subscale.
Vandiver et al., (2002) found that internal consistency (coefficient alpha)
reliability of the measure’s six subscales ranged from .76 to .89. It was predicted that the
six subscales of the CRIS measure would be significantly correlated with similar
subscales from the Multidimensional Inventory of Black Identity (MIBI)
Scale. Indeed, five of the six subscales were correlated with the appropriate subscales
(Vandiver et al.), thus indicating evidence for the convergent validity of the scale.

26
As predicted, the six subscales of the CRIS measure exhibited low, non-
significant correlations with measures of social desirability (Balanced Inventory for
Desirable Responding), personality (Big Five Inventory), and self-esteem (Rosenberg
Self-Esteem Scale) (thus indicating evidence for the discriminant validity of the scale
Vandiver et al., 2002).
Assignment of Clinicians to Racial Identity Statuses. For this study, the six scales
were collapsed into three levels of racial identity. For the first, Pre-encounter, stage, the
scores of the three Pre-encounter scales were summed, then the total was divided by
three. For the Immersion/Emersion stage, the scale of that name was used. For the third
stage, Internalized, the scores of the two Internalized scales were summed and the total
was divided by two.
The final step was to assign a person to one of the three resulting stages of racial
identity development. This was done on the basis of the highest score.
To test this assignment, repeated measures ANOVAs were run for each classified group
of clinicians. For those categorized at the Internalized stage, there was a statistically
significant difference between the several measures (F = 1311.49, p < .0001). For this
group of clinicians the mean scores for the several scales were as follows: Pre-Encounter,
8.64; Immersion/Emersion, 9.00; and Internalization, 21.36.
For clinicians categorized as at the Immersion/Emersion stage, a repeated
measures ANOVA showed a statistical difference between the several measures (F =
119.95, p <.0001). For this group of clinicians the mean scores for the several scales were
as follows: Pre-Encounter, 6.83; Immersion/Emersion, 22.67; and Internalization, 14.13.

27
For clinicians categorized as at the Pre-encounter stage, a repeated measures
ANOVA showed a statistical difference between the several measures (F = 37.27, p <
.001). For this group of clinicians the mean scores for the several scales were as follows:
Pre-Encounter, 17.78; Immersion/Emersion, 5.87; and Internalization, 11.79.
Manipulation of Racial Identity of Client
The three levels of racial identity of the hypothetical client were manipulated
through client descriptive information embedded in a vignette. The vignette (see
Appendix A) described “Tracy Hamilton, a 32-year-old, overweight and visibly angry
African-American” who had been referred for evaluation after behaving angrily in a
school principal’s office.
All vignettes were identical except for material in the second and third
paragraphs. This material was as follows:
Material signaling a client at the Pre-Encounter stage. Mrs. Hamilton stated that
her suspicions concerning her child’s unfair treatment in school were well-
founded and that she would harm no one. She reportedly told her son’s school
principal that she is not looking for a “hand out” for her son. She said she is a
proud American and will continue to work hard and encourage her child to do
the same. She acknowledged that she was particularly irritable and angry
because she recently argued with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical
examination. When she saw the psychiatrist the next day, she appeared to be a
“different” person. She was relaxed her anger and irritability had dissipated,
and she displayed a sense of humor. However, she retained her conviction that

28
the school principal owed her an explanation of his unfair treatment of her
child. She went on to state that she thinks of herself primarily as an American,
and seldom as a member of a racial group. She said, “I’m not a whiner, I
know when people look at me they think I’m like other Blacks, complaining
all day and refusing to work hard…I’m not like that.”
Material signaling a client at the Immersion-Emersion stage. Mrs. Hamilton
stated that her suspicions concerning her child’s unfair treatment in school
were well-founded and that she would harm no one. She reportedly told her
son’s school principal that she is not looking for a “hand out” for her son. She
said she is a proud American and will continue to work hard and encourage
her child to do the same. She acknowledged that she was particularly irritable
and angry because she recently argued with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical
examination. When she saw the psychiatrist the next day, she appeared to be a
“different” person. She was relaxed her anger and irritability had dissipated,
and she displayed a sense of humor. However, she retained her conviction that
the school principal owed her an explanation of his unfair treatment of her
child. She went on to state that she thinks of herself primarily as an American,
and seldom as a member of a racial group. She said, “I’m not a whiner, I
know when people look at me they think I’m like other Blacks, complaining
all day and refusing to work hard…I’m not like that.”
Material signaling a client at the Internalization stage. Mrs. Hamilton stated that
her suspicions concerning her child’s unfair treatment in school were well-

29
founded and that she would harm no one. She reportedly told her son’s school
principal that although it may not have appeared to be so when in his office,
she is peaceful as she sees and thinks about things from an Afrocentric
perspective. She acknowledged that she was particularly irritable and angry
because she recently argued with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical
examination. When she saw the psychiatrist the next day, she appeared to be a
“different” person. She was relaxed her anger and irritability had dissipated,
and she displayed a sense of humor. However, she retained her conviction that
the school principal owed her an explanation of his unfair treatment of her
child. She went on to state that her anger is not about race specifically, stating,
“I am connected to many groups. I embrace my own Black identity but I also
respect and celebrate the cultural identities of other groups and I encourage
my child to do the same.”
Vignette Development
The vignette was adapted from one that had been published in the DSM IV
Casebook (Spitzer, Gibbon, Skodol, Williams, & First, 1994). It was chosen because it
depicted a case with elements both of a mood disorder, angry acting out, and family
stressors. Whereas the original case had featured menstrual phase determinants of the
clients behavior, those were eliminated from this description.
The racial identity salient portions of the description initially were written by directly
appropriating language used in items on the CRIS. However, those descriptions were

30
stilted and detracted from integrity of the case description and so they were reworked to
address those issues.
The next step was to bring in 15 (9 female; 6 male) African American graduates
of either MFT (masters) or and psychology (doctoral) programs who had been working as
a study group to prepare for their respective licensure examination.
They ranged in age from 26 to 49 and all worked in Los Angeles County in county
agencies where they provided psychotherapy to adolescents and adults. All were familiar
with the DSM IV.
The group was asked to participate in a focus group to help determine the validity
of three written vignettes. They were given a brief overview of Cross racial identity
model. Then, they were provided the three vignettes and asked for their impressions of
the vignettes including diagnosis and likeability. All participants identified the racial
identity status of the client appropriately. Diagnoses ranged from adjustment to mood and
anxiety related disorders. The majority of the therapists concluded that they were most
frustrated by the pre-encounter client. Participants reported finding the internalized client
most likeable followed by the immersion/emersion client and finally the pre-encounter
client.
Procedure
Recruitment of Participants
Emails were sent to multiple mental health and social service agencies asking for
contact information for African American therapist employees. As well, African
American friends and colleagues who were mental health professionals were asked to
forward the request to participate to as many of their own acquaintances as they could.

31
Given this strategy, it is not possible to know exactly how many people were invited to
participate; the best estimate is about 225.
It was decided not to approach groups such as the Association of Black
Psychologists because of the potential bias that might cause. That is, it was reasoned that
the factors that would motivate a psychologist to join those groups very likely would
affect his or her level of racial identity in some systematic way.
Data Collection
Data were collected via the internet using Surveymonkey.com. Prospective
participants were emailed an invitation to participate in this study which was desribed to
them as a “Validation Study on the Global Assessment of Functioning Scale of the DSM-
IV Axis V Scale” (appropriate IRB approvals had been obtained for this deception study).
They also were informed that their participation would enter them in a drawing for a
$200 gift card.
Participants were randomly assigned to read one of the three versions of the
vignette. Their tasks, then, were to read the vignette; to assign a GAF score; to write in
free-response form what they thought the most appropriate Axis 1 diagnosis might be;
and then to complete the Cross Racial Identity Scale (CRIS) (Vandiver et al., 2000).
After the data were collected, participants were debriefed by email. In this note,
they were informed of the true objective of the study and informed that if they wanted to
withdraw their data at that point they could. None did.

32
CHAPTER 3
RESULTS
This chapter reports the results of the study. Descriptive statistics are presented
first. Then, the research questions are examined. Last, exploratory data are presented.
Descriptive Statistics
Preliminary analyses were run to examine whether there were systematic
differences by participant profession and gender with respect to assigned GAF score.
Neither were statistically significant: profession (F = 1.45, p = .23); gender (F = .58, p =
.45). Table 1 reports client GAF scores by racial identity of client and of the mental
health professional. It demonstrates the large discrepancy in cell sizes created by the fact
that the substantial majority of the therapists were categorized as being at the internalized
stage of racial identity.
Table 2 reports categorical data for the Axis 1 diagnosis the clinicians had
provided. As noted in Chapter 2, these had been provided in free response form and then
coded into one of five categories: No diagnosis; adjustment disorder; mood disorder;
impulse control disorder; and psychotic disorder (recognizing that not all these categories
correspond to what the DSM would classify as Axis 1).

33
Table 1
Client GAF Scores by Racial Identity of Client and Mental Health Professional
Client Level of Racial Identity

Pre-Encounter
Immersion/
Emersion
Internalized TOTAL
Therapist Level of
Racial Identity
M SD N M SD N M SD N M SD N
Pre-Encounter 77.75 5.12 4 59.63 5.18 8 68.50 0.71 2 66.07 4.52 14
Immersion/
Emersion
56.67 5.51 3 81.00 2.00 3 77.33 2.58 6 73.08 3.17 12
Internalized 66.91 6.08 23 70.17 9.00 18 72.32 7.62 22 69.73 7.45 63
TOTAL 67.33 5.90 30 68.38 7.22 29 73.07 6.15 30 69.61 6.34 89

34
Table 2
Client Diagnosis by Racial Identity of Client and Mental Health Professional
No Diagnosis
Adjustment
Disorder
Mood Disorder
Impulse
Control
Disorder
Psychotic
Disorder
Therapist Level of
Racial Identity
N % N % N % N % N %
Client Level of Racial Identity: Pre-Encounter
Pre-Encounter
0 0.00 0 0.00 2 40.00 0 0.00 0 0.00
Immersion/Emersion
0 0.00 2 33.33 3 60.00 2 100.00 1 100.00
Internalized
0 0.00 4 66.67 0 0.00 0 0.00 0 0.00
TOTAL (Pre-
Encounter Client)
0 0.00 6 100.00 5 100.00 2 100.00 1 100.00
Client Level of Racial Identity: Immersion/Emersion
Pre-Encounter
0 0.00 1 25.00 5 83.33 0 0.00 0 0.00
Immersion/Emersion
0 0.00 3 75.00 0 0.00 0 0.00 0 0.00
Internalized
0 0.00 0 0.00 1 16.67 2 100.00 0 0.00
TOTAL (I/E Client)
0 0.00 4 100.00 6 100.00 2 100.00 0 0.00

35
Client Level of Racial Identity: Internalized
Pre-Encounter
0 0.00 7 35.00 13 37.14 1 33.33 1 33.33
Immersion/Emersion
2 100.00 7 35.00 8 22.86 0 0.00 1 33.33
Internalized
0 0.00 6 30.00 14 40.00 2 66.67 1 33.33
TOTAL
(Internalized Client)
2 100.00 20 100.00 35 100.00 3 100.00 3 100.00
TOTAL (All Clients) 2 2.2 30 33.3 46 52.2 7 7.8 4 4.4

36
Research Questions
The very small Ns in some of the cells made it possible to test only for main
effects. Therefore, the two research questions that concerned interaction effects were
dropped. The remaining research questions were examined as follows:
Research Question 1
Will the level of racial identity of an African-American client depicted in a vignette affect
the level of functioning African-American mental health professionals will perceive that
client to have?
A one-way analysis of variance (ANOVA) was run to examine this question.
The results were statistically significant: F(2, 86) = 4.08, p = .02. Post hoc analyses using
the Scheffé method revealed a statistically significant difference between the client
depicted as being at the Pre Encounter level and the client depicted as being at the
Internalized level (p = .031). There were no statistically significant differences in either
of the other two comparisons (Pre Encounter versus Immersion/Emersion;
Immersion/Emersion versus Internalized). These data are portrayed graphically in Figure
1.

37

Client Racial ID Levels
Internalized Immersion/Emersion Preencounter
Mean GAFScore
74.00
72.00
70.00
68.00
73.07
68.38
67.33

Figure 1. Mean GAF scores assigned the client depicted at each level of racial identity.

Research Question 2
Will level of racial identity of African-American mental health professionals affect the
level of functioning they ascribe to an African-American client depicted in a vignette?
A one-way analysis of variance (ANOVA) was run to examine this question.
The results were not statistically significant: F(2, 86) = 2.26, p = .111.

38
Research Question 3
Will the level of racial identity of an African-American client depicted in a vignette affect
the Axis I diagnosis African American mental health professionals will perceive that
client to have?
It was found that the client racial identity did not significantly impact the diagnosis that
health professionals assigned (χ(8) = 9.39, p = 0.31).
Research Question 4
Will level of racial identity of African-American mental health professionals affect the
Axis I diagnosis they ascribe to an African-American client depicted in a vignette?
For question 4, it was found that the mental health professional’s racial identity did not
significantly impact the diagnosis they assigned to the client (χ(8) = 5.58, p = 0.69).
Exploratory Analysis
The very small cell sizes precluded a valid statistic test of possible interactions of
client and therapist racial identity levels when the GAF score was the dependent measure.
Nevertheless, it is useful to consider the graphical representation of those data.
Figure 2 suggests the possibility that the racial identity of African American
therapists and African American clients would interact in assessments of the client’s

39
level of functioning. For example, these data depict the Internalized therapist giving a
much lower GAF score to the Pre-Encounter client than the Pre-Encounter therapist.
Summary
The small cell sizes precluded examination of interaction effects (research
questions 3 and 6). Of the remaining questions, statistical significance obtained for only
one: there was a main effect for client racial identity level, with the pre-encounter client
being given a significantly lower GAF score than the internalized client.
Although it was not possible to conduct valid statistical tests for interaction
effects, those differences were portrayed graphically. Those results, however tentative,
suggest the promise of further exploration of this question.

40
Client Racial ID Levels
Internalized Immersion/Emersion Preencounter
Mean GAFScore
85.00
80.00
75.00
70.00
65.00
60.00
55.00
72.32
70.17
66.91
77.33
81.00
56.67
68.50
59.62
77.75
Internalized
Immersion/Emersion
PreEncounter
Internalized
Immersion/Emersion
PreEncounter
Therapist Racial
Identity Levels

Figure 2. Mean GAF scores by Client and Therapist levels of racial identity.

41
CHAPTER 4
DISCUSSION

This chapter considers the meaning and implications of the study’s findings. It begins
with a discussion of those findings, then addresses in turn the study’s limitations and then
suggests directions for future research.
Discussion of the Findings
This was the first study to examine the extent to which racial identity of African-
American therapists and African-American clients predicted therapist ratings of client
functioning. It turned out that the most important finding may have been the incidental
one that nearly three-fourths (71%) of the therapists were in the internalized stage of
racial identity. From the perspective of the field, this is quite good news.
Because higher levels of racial identity development have been associated with
stronger self-concepts as well as personal self-esteem (Helms, 1990; Rowley, Sellers,
Chavous & Smith, 1998), the proportions of clinicians at the internalization stage is an
important indicator that African American therapists have generally high levels of mental
health. It also has treatment implications, for reasonably the racial identity level of the
therapist can operate as a ceiling for that of the client she or he sees. Certainly, there are
many forces in a client’s life, but a therapist’s own level of functioning can have
particular influence on the client, as Carkhuff (1969) so cogently argued many years ago.
It is reasonable to speculate about what might account for this generally high level
of racial identity development. There are several possibilities, none of which are mutually

42
exclusive. The first is that African Americans who are drawn into the field are people
who already have achieved higher levels of racial identity.
A second possibility is that graduate training-- particularly in areas related to
diversity – had what was, in effect, a therapeutic effect on these students. That is, as a
function of graduate school their racial identity levels were enhanced. Abreu, Chung, and
Atkinson (2000) argued that due to calls to action from mental health professionals
regarding multicultural counseling (MCC), increasing numbers of people of color
represented in training programs, and the growing recognition of the need for MCC,
trends have been moving toward an increased volume of MCC courses required in
training programs. It could be that the relatively high level of racial identity of these
participants is an indicator of the success of these courses. Although these clinicians were
not asked about their multicultural competence or related training, it is possible that they
had received MCT and that those experiences have helped progress trainees toward an
internalized racial identity status.
The third possibility is that the practice of doing therapy is itself therapeutic. This
was the thesis many years ago in Reissman’s (1965) helper-therapy principle. In fact, he
asserted that providing therapy may result in greater therapeutic effects on the therapist
than on those he or she is attempting to serve. If it is true that race is always a salient
issue for people of color, then an African American therapist would in working with
clients have the opportunity continually to reflect on all aspects of his or her identity, but
especially that related to race.
The final possibility is that there was selection bias. Approximately forty percent
of those who were invited to participate did so, leaving 60 percent who chose not to. It is

43
possible, therefore, that those therapists who were functioning at higher levels of racial
identity were more likely to participate. The explanation of the study itself would not
have served as an identity-salient cue. However, perhaps they were more inclined to
participate in research because of greater curiosity and so on. Given the very high
proportion of the respondents who were at that internalized stage, selection bias is an
improbable explanation, but one still worth acknowledging.
Race as a Factor
Garb (1998) concluded from his review that African-American psychiatric clients
were perceived to be more violent than their White counterparts. Further, African-
American clinical clients have been overdiagnosed and misdiagnosed with serious
psychiatric afflictions when compared to their White counterparts (Adebimpe, 1981;
Rosenthal & Bervin, 1999; Whaley, 1998). These studies focused primarily on the
relationship between different races.
A particular strength of this study, though, was that it focuses specifically on one
racial group: Both the depicted client and the participating clinicians were African-
American. This is not to say that African-Americans are not subject to racial stereotypes
about other African-Americans (cf., Loring & Powell, 1988). However, it does decrease
the “noise” race creates during the making of diagnostic decisions.
Results Related to the Research Questions
That such a high proportion of respondents were at the internalizing stage is good
for the field, for the reasons already noted above. However, it significantly affected this
study, rendering many cell sizes too small to permit an examination of interaction effects.

44
Client Racial Identity and GAF Scores. The one significant finding obtained in
this study was that client racial identity levels affected clinicians’ perceptions of the
client’s level of functioning, as assessed via GAF score. Moreover, there was a near-
linear trend whereby the lowest GAF scores were accorded to the Pre-Encounter client
and the highest to the Internalized client.
There are two possible explanations for this finding. The first concerns clinician
bias. Indeed, that was the way the study had been framed in the first place. Specifically, it
was grounded in the assumption that differential assignment of levels of functioning
according to client’s racial identity level is an artifact of the clinician’s world view.
The alternative explanation, though, is that the results reflect actual differences in
client functioning. In fact, this is consistent with studies showing that racial identity
levels are associated with higher levels of functioning (Helms, 1990; Rowley, Sellers,
Chavous & Smith, 1998). It is particularly interesting to note the finding by Nghe and
Mahalik (2001) that clients who were deemed as being in the internalization level of
racial identity used more healthy and mature psychological defense mechanisms than
those at lower levels of racial identity. More mature psychological defense mechanisms
should yield higher levels of functioning that a therapist ascribes to a client.
To accept this explanation of actual differences in level of functioning does not
render racial identity an irrelevant matter. In fact, from a treatment perspective,
understanding the client’s racial identity level could be very helpful in planning how the
therapist would perceived and which particular arguments to make (Helms, 1986).
The graphical representation of the data on possible interactions between client
and therapist racial interactions was intriguing. These suggest that had a sample of

45
sufficient size had been obtained, it might have been possible to demonstrate these
interactions statistically. Were that the case, then it would be possible to make a clearer
argument for bias. Whaley (1998), for example, had suggested that perceptions based on
raters’ unexamined stereotypes often have a negative impact on the diagnostic process –
and stereotypes related to racial identity often are unexamined.
Client Racial Identity and Axis 1 Scores. Small cells again were a problem in
analyzing the Axis 1-related findings. That is, the SPSS chi-square analyses were
nonsignificant. Yet a visual inspection showed clear differences in the diagnoses,
regardless of client racial or therapist racial identity level.
The majority (52%) of the clinicians indicated that the appropriate diagnosis was
a mood disorder. Because the vignette was developed from a description of a mood
disordered client, this should be seen as an expected finding.
Limitations
Any study has limitations. There are several in this case that warrant
acknowledgement.
Focusing on African American clinicians made recruitment a particular challenge.
The problem of small cell sizes already has been acknowledged. However, it would be
interesting in a larger study to focus exclusively on psychologists (or on one of the other
professions reflected in this study). Even though no between-profession difference was
found in this study with respect to level of GAF scores assigned, it is reasonable to
assume that different professions have different ways of using the DSM and therefore, of
conceptualizing clients.

46
It is a strength of this study that it focused only on African Americans. As noted
above, this helped control for possible racial bias. However, this also was a limitation in
that these results cannot be applied to other ethnic or racial groups, or other professional
groups. In fact, to have the perspective of clinicians of other racial or cultural groups
could help interpret the meaning of these obtained findings.
Using a client with the modal presenting behavior indicative of a mood disorder
seemed a logical choice for this study. However, we are left to wonder how clinicians
might have perceived a client whose behaviors were markedly different. That is, would
client racial identity continue to moderate impressions of that client?
Recommendations for Future Research
This study leaves us with numerous potential areas for future research. First, the
study might benefit from a larger sample size. As noted in the previous chapter, some
findings may have been obscured or complicated due to a relatively small sample size.
By increasing the size of the sample, the validity and accuracy of the results are also
potentially increased, which would potentially verify the accuracy of these preliminary
findings.
Further, a subsequent study might focus on mental health professionals and clients
of different racial and ethnic groups, such as Hispanic Americans and Asian Americans.
Perceptions of racial identity vary dramatically among different racial groups as a
function of social, economic, historical, and geographical factors. Race and racial identity
could affect assessment very differently with respect to other racial groups. Therefore, to
apply the methods of this study to other racial and ethnic groups would provide data that
would help further interpret this study’s findings, but also potentially extend our

47
understanding of the role of racial identity and its influence on clinician impressions
generally.
Other studies might also examine how the level of racial identity is associated
with other aspects of mental health professionals’ judgment, conclusions, and diagnoses.
This study considered a very specific type of therapist analysis, the level of functioning
of a client. However, there is a whole scope and range of decisions and judgments that
professional therapists, both African-American and other ethnicities, must make. Race
and racial identities could potentially play a role in other aspects of therapist decisions.
This research demonstrated that the levels of racial identity of African American
clients affects the African American therapist’s conclusions regarding the client’s level of
functionality. Helms (1990) created a model to explain how racial and ethnic identities
interact to affect relationships and perceptions the parties have of one another. To have a
better understanding of the factors contributing to racial identity and bias could
potentially elucidate this subject even more and lead to new models explaining the nature
of interaction between clients and therapists. Focusing specifically on the relationship
between clients and therapists of the same race (African-American in this case) has
particular value in this case.
Some researchers and theorists have offered a comprehensive look at the stages of
racial identity development. Yet the relative dearth of information concerning the role of
race and racial identity with respect to therapist diagnoses must continue to be explored.
Though this study points to the possibility of client racial identity affecting the
conclusions of therapists, the inherent reasons for this are unexplained. Existing research

48
needs to be further adapted to the findings of this study, and future research must attempt
to explain why the level of racial identity has this effect.
Summary
This particular study aimed to build upon the literature regarding race, therapy,
and assessment, focusing particularly on the association between racial identity and
therapist judgment. Its primary finding was that the racial identity level of a client was
associated with the level of functioning ascribed by the clinicians. Although other
components of the therapists’ diagnoses were not significantly associated with race or
level of racial identity, this study establishes a foundation for which future research might
be built.

49
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APPENDIX A
Vignettes Used in the Study

55
Pre-encounter
Tracy Hamilton, a 32-year-old, overweight and visibly angry African-American
woman was referred to your office after she had furiously shattered a full-length mirror in
the office of her child’s school principal. The school principal, a slightly built, White,
middle-aged woman left the office and refused to meet with Mrs. Hamilton. The school
psychologist on site observed the incident and described her as “paranoid and dangerous
to others” and recommended immediate treatment and a medication evaluation.
Mrs. Hamilton stated that her suspicions concerning her child’s unfair treatment
in school were well-founded and that she would harm no one. She reportedly told her
son’s school principal that she is not looking for a “hand out” for her son. She said she is
a proud American and will continue to work hard and encourage her child to do the same.
She acknowledged that she was particularly irritable and angry because she recently
argued with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical examination.
When she saw the psychiatrist the next day, she appeared to be a “different” person. She
was relaxed her anger and irritability had dissipated, and she displayed a sense of humor.
However, she retained her conviction that the school principal owed her an explanation of
his unfair treatment of her child. She went on to state that she thinks of herself primarily
as an American, and seldom as a member of a racial group. She said, “I’m not a whiner, I
know when people look at me they think I’m like other Blacks, complaining all day and
refusing to work hard…I’m not like that.”
Mrs. Hamilton was the oldest daughter of a chronically depressed and fearful
mother and an alcoholic businessman father. Before marriage, she was the caretaker of

56
her family. Her mother recovered significantly during Mrs. Hamilton’s adolescence, only
to fail rapidly and die when her daughter left home and married after high school.
Mrs. Hamilton is the mother of four grade-school children; in addition, she has
primary responsibility for an alcoholic sibling who is dying of cancer, as well as for her
handicapped husband, who has been severely depressed and vocationally incapacitated
since surgery 1.5 years ago. She lives with her in-laws. Both her husband and his parents
have significant alcohol problems.
Mrs. Hamilton is still the family caretaker. “I can’t live with myself unless I do it
all. I feel guilty if I do something for myself.” She can cope with the demands of her life
and is not usually depressed, except on occasion when “the whole world closes in” and
she feels “pulled down.”

57
Immersion-Emersion
Tracy Hamilton, a 32-year-old, overweight and visibly angry African-American
woman was referred to your office after she had furiously shattered a full-length mirror in
the office of her child’s school principal. The school principal, a slightly built, White,
middle-aged woman left the office and refused to meet with Mrs. Hamilton. The school
psychologist on site observed the incident and described her as “paranoid and dangerous
to others” and recommended immediate treatment and a medication evaluation.
Mrs. Hamilton stated that her suspicions concerning her child’s unfair treatment
in school were well-founded and that she would harm no one. She reportedly told her
son’s school principal that she has a strong feeling of hatred and disdain for all White
people and added that she is in no way surprised that her son is “targeted at school.” She
acknowledged that she was particularly irritable and angry because she recently argued
with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical examination.
When she saw the psychiatrist the next day, she appeared to be a “different” person. She
was relaxed her anger and irritability had dissipated, and she displayed a sense of humor.
However, she retained her conviction that the school principal owed her an explanation of
his unfair treatment of her child. She went on to state that her son’s principal’s behavior
only strengthened her position of hating “the White community and all it represents.”
Mrs. Hamilton was the oldest daughter of a chronically depressed and fearful
mother and an alcoholic businessman father. Before marriage, she was the caretaker of
her family. Her mother recovered significantly during Mrs. Hamilton’s adolescence, only
to fail rapidly and die when her daughter left home and married after high school.

58
Mrs. Hamilton is the mother of four grade-school children; in addition, she has
primary responsibility for an alcoholic sibling who is dying of cancer, as well as for her
handicapped husband, who has been severely depressed and vocationally incapacitated
since surgery 1.5 years ago. She lives with her in-laws. Both her husband and his parents
have significant alcohol problems.
Mrs. Hamilton is still the family caretaker. “I can’t live with myself unless I do it
all. I feel guilty if I do something for myself.” She can cope with the demands of her life
and is not usually depressed, except on occasion when “the whole world closes in” and
she feels “pulled down.”

59
Internalization
Tracy Hamilton, a 32-year-old, overweight, and visibly angry African-American
woman was referred to your office after she had furiously shattered a full-length mirror in
the office of her child’s school principal. The school principal, a slightly built, White,
middle-aged woman left the office and refused to meet with Mrs. Hamilton. The school
psychologist on site observed the incident and described her as “paranoid and dangerous
to others” and recommended immediate treatment and a medication evaluation.
Mrs. Hamilton stated that her suspicions concerning her child’s unfair treatment
in school were well-founded and that she would harm no one. She reportedly told her
son’s school principal that although it may not have appeared to be so when in his office,
she is peaceful as she sees and thinks about things from an Afrocentric perspective. She
acknowledged that she was particularly irritable and angry because she recently argued
with her employer.
You have referred Mrs. Hamilton to a psychiatrist for a medical examination.
When she saw the psychiatrist the next day, she appeared to be a “different” person. She
was relaxed her anger and irritability had dissipated, and she displayed a sense of humor.
However, she retained her conviction that the school principal owed her an explanation of
his unfair treatment of her child. She went on to state that her anger is not about race
specifically, stating, “I am connected to many groups. I embrace my own Black identity
but I also respect and celebrate the cultural identities of other groups and I encourage my
child to do the same.”
Mrs. Hamilton was the oldest daughter of a chronically depressed and fearful
mother and an alcoholic businessman father. Before marriage, she was the caretaker of

60
her family. Her mother recovered significantly during Mrs. Hamilton’s adolescence, only
to fail rapidly and die when her daughter left home and married after high school.
Mrs. Hamilton is the mother of four grade-school children; in addition, she has
primary responsibility for an alcoholic sibling who is dying of cancer, as well as for her
handicapped husband, who has been severely depressed and vocationally incapacitated
since surgery 1.5 years ago. She lives with her in-laws. Both her husband and his parents
have significant alcohol problems.
Mrs. Hamilton is still the family caretaker. “I can’t live with myself unless I do it
all. I feel guilty if I do something for myself.” She can cope with the demands of her life
and is not usually depressed, except on occasion when “the whole world closes in” and
she feels “pulled down.”

61
Cross Racial Identity Scale

.
1 strongly disagree 2 disagree 3 somewhat disagree 4 neither disagree nor agree 5
somewhat agree 6 strongly agree

1. As an African American, life in America is good for me.
2. I think of myself primarily as an American, and seldom as a member of a racial group.
3. Too many Blacks “glamorize” the drug trade and fail to see opportunities that don’t
involve crime.
4. I go through periods when I am down on myself because I am Black.
5. As a multiculturalist, I am connected to many groups (Hispanics, Asian-Americans,
Whites, Jews, gays & lesbians, etc.).
6. I have a strong feeling of hatred and disdain for all White people.
7. I see and think about things from an Afrocentric perspective.
8. When I walk into a room, I always take note of the racial make-up of the people
around me.
9. I am not so much a member of a racial group, as I am an American.
10. I sometimes struggle with negative feelings about being Black.
11. My relationship with God plays an important role in my life.
12. Blacks place more emphasis on having a good time than on hard work.
13. I believe that only those Black people who accept an Afrocentric perspective can
truly solve the race problem in America.
14. I hate the White community and all that it represents.
15. When I have a chance to make a new friend, issues of race and ethnicity seldom play
a role in who that person might be.
16. I believe it is important to have both a Black identity and a multicultural perspective,
which is inclusive of everyone (e.g., Asians, Latinos, gays & lesbians, Jews, Whites,
etc.).
17. When I look in the mirror at my Black image, sometimes I do not feel good about
what I see.
18. If I had to put a label on my identity, it would be “American,” and not African
American.
19. When I read the newspaper or a magazine, I always look for articles and stories that
deal with race and ethnic issues.
20. Many African Americans are too lazy to see opportunities that are right in front of
them.
21. As far as I am concerned, affirmative action will be needed for a long time.
22. Black people cannot truly be free until our daily lives are guided by Afrocentric
values and principles.
23. White people should be destroyed.
24. I embrace my own Black identity, but I also respect and celebrate the cultural
identities of other groups (e.g., Native Americans, Whites, Latinos, Jews, Asian
Americans, gays & lesbians, etc.).
25. Privately, I sometimes have negative feelings about being Black.
26. If I had to put myself into categories, first I would say I am an American, and

62
member of a racial group.
27. My feelings and thoughts about God are very important to me.
28. African Americans are too quick to turn to crime to solve their problems.
29. When I have a chance to decorate a room, I tend to select pictures, posters, or works
of art that express strong racial-cultural themes.
30. I hate White people.
31. I respect the ideas that other Black people hold, but I believe that the best way to
solve our problems is to think Afrocentrically.
32. When I vote in an election, the first thing I think about is the candidate’s record on
racial and cultural issues.
33. I believe it is important to have both a Black identity and a multicultural perspective,
because this connects me to other groups (Hispanics, Asian-Americans, Whites, Jews,
gays & lesbians, etc.).
34. I have developed an identity that stresses my experiences as an American more than
my experiences as a member of a racial group.
35. During a typical week in my life, I think about racial and cultural issues many, many
times.
36. Blacks place too much importance on racial protest and not enough on hard work and
education.
37. Black people will never be free until we embrace an Afrocentric perspective.
38. My negative feelings toward White people are very intense.
39. I sometimes have negative feelings about being Black.
40. As a multiculturalist, it is important for me to be connected with individuals from all
cultural backgrounds (Latinos, gays & lesbians, Jews, Native Americans, Asian-
Americans, etc.).

Abstract (if available)

Abstract This was the first study to examine the relationship between racial identity status of both clinicians and a client depicted in a vignette and the diagnostic impressions of those clinicians. Participants were 89 African American mental health professionals (53 female, 36 male). They were randomly assigned to read one of three versions of a vignette describing an African American woman with a mood disorder. In each version, though, descriptors were chosen to signal one of three levels of racial identity: Pre-encounter, Immersion-Emersion, and Integrated. They then were asked to (a) assess that client's level of functioning using the /DSM-IV/ Global Assessment of Functioning Axis V Scale (GAF) and (b) provide an Axis I diagnosis. They also completed the Revised Cross Racial Identity Scale (CRIS), which then was used to assign them to one of three levels of racial identity: Pre-encounter, Immersion-Emersion, and Internalized. Because 71% of the participants were in the Internalized stage of racial identity, there were insufficient cell sizes to examine interaction effects. However, main effects were examined for racial identity levels of the clinicians and of the client. Significant between-group differences were obtained for client racial identity levels, with a near-linear trend whereby GAF scores for the Pre-encounter client were lowest, with successively higher scores for the Immersion/Emersion and the Integrated client, in turn. No other differences were found.

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Creator Bush, Saul Thomas (author)

Core Title Correspondence between level of racial identity of African-American therapists and of a vignette-depicted African-American client and assessed client problem severity

School Rossier School of Education

Degree Doctor of Philosophy

Degree Program Education (Counseling Psychology)

Publication Date 12/16/2008

Defense Date 10/23/2008

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag African American mental health,assessment bias,clinical judgment,global assessment of functioning (GAF),OAI-PMH Harvest,psychological diagnoses,racial identity development

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Goodyear, Rodney K. (committee chair), Davidson, Gerald (committee member), Stone, Gerald (committee member)

Creator Email saulbush@earthlink.net,saulbush@sbcglobal.net

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m1934

Unique identifier UC1275960

Identifier etd-Bush-2541 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-146038 (legacy record id),usctheses-m1934 (legacy record id)

Legacy Identifier etd-Bush-2541.pdf

Dmrecord 146038

Document Type Dissertation

Rights Bush, Saul Thomas

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu