Conceptualizing diagnosis through a social justice lens

By Christine Banks-VanAllen

May 2023

Arianna and her grandmother sit on opposite sides of the cramped counseling office with their arms crossed, looking away from each other. The tension in the room is palpable. You offer Arianna a glass of water, and after introducing yourself, you invite her to share what brought her into your office today. Her grandmother glances up at you, while Arianna continues to gaze downward, methodically twirling her scuffed phone in her hands.

In this first session, you learn that Arianna, who is a 16-year-old African American adolescent, has recently been suspended from school following her third fight this school year. As a child, Arianna had adverse experiences, including physical neglect, parental separation and parental addiction, and she was placed in the custody of her grandmother at age 6. She exhibits anger and aggression toward her younger siblings and is failing several classes in school because she doesn’t turn in her work. Arianna tells you she has been diagnosed with a range of mental health disorders, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and major depressive disorder (MDD).

Her grandmother turns to you and says in an exasperated tone, “Her medication just isn’t working anymore. Please talk some sense into her.”

As Arianna’s new counselor, what are your initial diagnostic impressions? What cultural considerations strike you as the most relevant in her case? How might her experiences of early adversity shape her symptoms today, and what might these different diagnostic labels mean to her? How might your diagnostic impressions change if Arianna was of a different age, race, class or gender?

In most practice settings, counselors use diagnosis in assessment, case conceptualization, treatment planning and managed care reimbursement. Unfortunately, the use of diagnosis across mental health professions has a complicated history with respect to multiculturalism and social justice. Diagnostic classification has been used as a tool of oppression throughout history by defining societal conceptions of “normal” and “abnormal” and pathologizing “otherness” under the guise of medical and scientific objectivity. Diagnosis tends to place the onus of psychological dysfunction on individuals, with historically limited regard for the cultural, systemic and ecological factors shaping individuals’ experiences. Counselors confront important philosophical and ethical questions regarding multiculturalism and social justice as we conceptualize our relationship with diagnosis. This article examines the historical legacy of diagnosis and offers considerations for infusing social justice into counselors’ diagnostic practices.

Historical prejudice in diagnostic classification

Behaviors defined as mental illness have historically been those that violate societal expectations of appropriate behavior within a given context. Definitions of “normal” and “abnormal” are rooted in socially dominant conceptions of what acceptable behavior should be in sociocultural context. Deviance from socially constructed definitions of “normal” has historically led to pathologization of those not conforming to social expectations, while simultaneously placing the blame of pathology within the individual. For example, early attempts at classifying mental disorders included pseudoscience theories such as phrenology (the debunked “study” of skull shape and size used to classify people’s intelligence, personality and abilities that led to “scientific” rankings of race and gender) and drapetomania (a term coined by Samuel A. Cartwright in 1851 to describe a “mental illness” that caused enslaved people to want to escape from captivity). These two theories are clear examples of scientific racism that advanced the use of medical classification to pathologize both otherness and individuals’ adaptive responses to coping with trauma.

Although mental health diagnoses have progressed and moved away from these diagnostic ghosts of our past, they continue to focus on symptoms of psychological distress occurring within the individual, rather than within the broad culture, community and society in which the individual exists. It doesn’t matter if it is society’s prejudices and oppressions that traumatize its members; individuals carry the “disorder” of living with adversity.

Autism spectrum disorder, for example, has experienced a shift in diagnostic framing over time. In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), what we now consider autism spectrum disorder was labeled as “childhood schizophrenia” and was used to justify the widespread institutionalization of people with autism. Over time, the conceptualization of autism has shifted into that of a neurodevelopmental disorder, assimilating previous diagnoses of pervasive developmental disorder not otherwise specified, childhood disintegrative disorder and Asperger’s disorder along the way. This assimilation of related diagnoses marks one reason why the prevalence of autism has risen so drastically over the past several decades.

Another important reason for this rise includes better diagnostic awareness that autism can be found in individuals who are not young, white or male. The revised fifth edition of the DSM states that boys are four times more likely to be diagnosed with autism than girls, and that most girls are “missed” unless their autistic symptoms are accompanied by significant cognitive impairments. Autism also continues to be underdiagnosed in young people of color and, if diagnosed, tends to be diagnosed later than in white youth.

Furthermore, the neurodivergence movement views neurodevelopmental disorders such as autism and ADHD as a form of identity rather than a disorder or a disability, and the impact of difference only becomes problematic within the context of a nonsupportive environment. At the same time, diagnosis continues to enable individuals with autism access to much-needed care and support, which places these individuals in a precarious balance between labels of disability and neurodivergence. Is autism a mental disorder, a form of disability or a type of neurodiversity? Perhaps in another 50 years, we’ll know.

Complicating matters further is the medicalization of diagnosis used today in accessing reimbursement. The first editions of the DSM espoused a markedly psychoanalytic bent, where disorders represented reactions of the personality. The medical model, introduced in the third edition of the DSM, launched the DSM’s gradual descent into the medicalization of diagnosis and the use of diagnosis to justify treatment. The perceived objectivity we see in diagnosis today — ticking off symptom boxes and diagnosing based on clusters of symptoms — often misses the underlying causes of distress, the sources of our clients’ psychaches.

The parable of the blind men and an elephant illustrates the problem with diagnosing in isolation. A group of blind men each describe what they believe an elephant must be based on touching individual parts of the elephant. One man, feeling the elephant’s trunk, believes it is a snake. Another, feeling the elephant’s leg, believes it is a tree trunk. A third, feeling the elephant’s tail, believes it is a rope. When we diagnose disparate symptoms as disparate diagnoses, we tend to treat individual symptoms in isolation from one another and fail to see the whole elephant.

Do Arianna’s three diagnoses of ADHD, ODD and MDD help us to see her psychache more clearly or have we missed the elephant? How do we as counselors conceptualize mental health issues that are difficult to treat such as trauma or the oppressions of an unjust society? How do we balance the historical legacy of using diagnostic classification to pathologize otherness with the present-day reality that those same diagnoses are now used to secure rights and access to care for previously marginalized individuals? The same diagnoses that complicate Arianna’s care also afford her the ability to sit in your office seeking mental health care. To put it simply, it’s complicated.

Conceptualizing diagnosis

In many cases, diagnosis benefits clients. Having a name for their symptoms can be tremendously validating for many clients. It allows them to understand their experiences and recognize that they are not alone in their distress. Diagnosis also allows clients access to needed services, such as school-based supports for youth with neurodevelopmental disabilities or gender-affirming care for transgender individuals. And nearly ubiquitously in the world of managed care, diagnosis is used to justify reimbursement and payment for counseling services, enabling individuals to afford mental health care.

My relationship with diagnosis became personal when my son was diagnosed with autism spectrum disorder in 2021. At the time, his diagnosis came as a surprise to me. I was sure that his language delays were related to him being isolated from his peers during the COVID-19 pandemic and that his rigidities stemmed from the anxiety he had unfortunately inherited from me. In the nearly 18 months since receiving his diagnosis, I have come to recognize many benefits of mental health diagnosis. I no longer describe his pattern of pacing around the perimeter of rooms as “orbiting.” I now see it as a form of visual stimming, a self-soothing repetitive behavior he uses to self-regulate when he is either over- or understimulated. Naming precedes understanding; learning to name his symptoms and his condition has allowed me to better understand and accommodate his needs. Additionally, his diagnosis has enabled our family to access vital community supports — including special education services and support from our county board of developmental disabilities — and financial reimbursements through our family’s private health insurance.

However, as in the case of Arianna, mental health diagnosis can pose problems. Many counselors experience a philosophical divide between the counseling profession’s strength-based orientation and the medical-model orientation used in the DSM. Although the DSM describes itself as a value-free, scientific manual of mental illness, dominant cultural values remain entrenched in the structure and content of the DSM, reflecting historical and societal trends regarding definitions of normal and abnormal behaviors.

Diagnosis has the greatest potential to harm individuals from nondominant cultural groups, for whom over-, under- and misdiagnosis may add additional stigmatization onto existing layers of oppression. Consider the following:

• Among African Americans, paranoia may be a healthy and adaptive coping strategy against societal violence and oppression.
• African Americans often face a minimization of symptoms due to a false perception that they feel less pain than other racial groups. Conversely, African Americans are overrepresented in inpatient and psychiatric emergency room settings and are more likely to receive severe or persistent diagnoses (such as schizophrenia) over other affective disorders.
• Women are more likely to receive a mental health diagnosis than men. Women’s reported pain symptoms have historically been minimized as hysterical or hypochondriacal.
• Men are less routinely screened for eating disorders and sexual abuse.
• Diagnosis rates are higher among lower socioeconomic groups. Rates of coerced treatment increase with rates of economic decline.
• An increasing number of children receive diagnoses that are perceived to be severe and lifelong.
• Long-term effects of antipsychotic medication use in children are unknown but may include obesity, diabetes, cardiovascular issues and possible reduced life expectancy.
• ADHD rates are growing across the United States, with some of the highest rates observed among children in low-income communities and in children identifying as multiracial.

In comparing my son’s diagnostic experiences with Arianna’s, the differences appear striking. While my son’s diagnosis provides an explanation of his symptoms, a name that neatly packages the etiology of the disorder with his present-day symptoms, Arianna’s does not. As a trauma-focused counselor, I wonder whether Arianna’s present-day symptoms spanning elements of inattention, mood dysregulation, impulsivity and behavioral outbursts represent not three distinct disorders but diverse manifestations of how she has learned to cope with early adversity in her life. And what might these three distinct diagnoses — possibly being interpreted by Arianna as three different things wrong with her — mean to her?

Having the privilege to name someone else’s experience for them through the giving of a diagnosis is a power I hope we as counselors never take for granted. My son’s diagnosis provided feelings of empowerment, understanding and access, but Arianna’s diagnoses, on the other hand, seem to have fostered feelings of frustration, shame and helplessness. I also can’t help but wonder how Arianna’s positionality as a young African American woman might have shaped her diagnostic experiences differently than my experiences seeking care for my young white son.

Integrating social justice into diagnosis

The ethics of mental health diagnosis extend past the bounds of the counseling profession: Recall that the DSM is published by the American Psychiatric Association and that counselors have never been included alongside psychiatrists in revising the manual we are tasked to use. So counselors must remain mindful that by engaging in diagnosis, we are responsible for approaching diagnosis from the social justice lens of our own professional philosophy.

Fortunately, counselors have several tools at our disposal to approach diagnosis from a philosophy of social justice. Our first tool is the 2014 ACACode of Ethics, which includes the following standards that inform counselors’ ethical decision-making process around diagnosis.

• Proper Diagnosis (Standard E.5.a.): Counselors must carefully select and appropriately use assessment techniques “to provide proper diagnosis of mental disorders.” This means that counselors must make accurate diagnoses based on clients’ presenting symptoms and life experiences. Diagnoses should not inflate symptoms to appease reimbursement entities, nor should diagnoses downplay symptoms to avoid potentially stigmatizing diagnoses.
• Cultural Sensitivity (Standard E.5.b.): Counselors must consider clients’ cultural factors when conceptualizing diagnosis. We must remain mindful of how culture shapes both our clients’ and our own understandings of distress and how oppressive cultural factors may shape development of mental distress in the first place.
• Historical and Social Prejudices in the Diagnosis of Pathology (Standard E.5.c.): Counselors must recognize patterns of historical misdiagnosis and pathologization among oppressed groups. This means that we must understand how diagnosis has been used historically to pathologize otherness and make present-day diagnoses that support equity and justice for all clients.
• Refraining From Diagnosis (Standard E.5.d.): Counselors must consider the positive and negative implications of diagnosis and refrain from making diagnoses that may harm clients.

Taken together, these standards in our ACA Code of Ethics highlight the importance of diagnosing intentionally and with an awareness of how diagnosis may be used to help or harm.

The Multicultural and Social Justice Counseling Competencies provide us with another tool. As a socioecological model, these competencies recognize that multicultural and social justice work does not operate only in the domain of the intrapersonal but also within linked systems of oppression that must be addressed if we are to do good with our individual clients. The following paragraphs offer recommendations for conceptualizing diagnosis through the lens of social justice, as organized around the attitudes and beliefs, knowledge, skills, and action-based competencies listed in the Multicultural and Social Justice Counseling Competencies. These recommendations are not exhaustive and are intended to offer introductory tools for beginning to approach diagnosis from a lens of social justice.

The first set of recommendations relates to counselors’ attitudes and beliefs about diagnosis and social justice. Before counselors can advance justice work for others, they must develop an awareness of how their own social identities, assumptions, beliefs and biases intersect with the social identities of clients and the counseling relationship.

• Contextualize diagnosis: Remember that diagnosis exists in a sociocultural, linguistic, political, economic and time-oriented context. Diagnostic classification systems and criteria are generally biased toward Western, Eurocentric/white, male, middle-class values and life experiences. When considering a diagnosis, ask yourself the following questions: Would you come to the same diagnostic conclusions in a different context or with a client of a different age, race, class or gender? Would you conceptualize their distress differently if you were of a different age, race, class or gender?
• Assess implicit biases: Consider taking the free Implicit Association Test (developed by Harvard University) to gauge areas of implicit bias that you may carry. Although we as counselors have the power to choose if or how we act on our biases, understanding our own hidden biases can build awareness of subtle racial, class-based or gendered perceptions that may shape our initial diagnostic impressions.
• Reflect on strengths: Although diagnostic criteria read like a list of problems or deficits, learn to conceptualize symptoms through the counseling profession’s strength-based lens. Reflect on clients’ strengths in coping with the distress of their symptoms, and the distress of society’s response to their symptoms. Help clients identify present-day “symptoms” that reflect past adaptive coping strategies.

The second set of recommendations relates to counselors’ knowledge about diagnosis and social justice. Counselors must understand how privilege and marginalization have been enacted within mental health diagnosis and develop knowledge around conceptualizing diagnosis from a philosophy of equity and justice for all clients.

• Know your population: Learn about the culture of clients you are likely to see in your practice. Diagnostic bias is more likely to occur when counselors do not fully understand the community or culture of the clients they serve. Seek professional development, consultation, supervision, readings or other forms of immersion to increase your cultural knowledge. Remember that it is not the client’s responsibility to teach you about their culture during the diagnostic assessment.
• Educate clients about their diagnosis: You may be surprised that many clients don’t even know that they have a diagnosis. When you make a diagnosis, take time to educate your clients about their diagnosis and explore what their diagnosis means to them. Provide diagnostic education in the context of your work together, rather than leaving clients to educate themselves on “therapy TikTok.”
• Educate other professionals: Although many allied professionals — including case managers, teachers, children’s service professionals, legal advocates and reimbursement entities — use diagnosis in their work, most have no formal training in diagnosis and may carry misperceptions about what diagnoses mean. Offer trainings to allied professionals to support informed, collaborative care in the community.
• Be mindful of trauma: Experiences of trauma are much more common and diverse than the DSM’s criteria for posttraumatic stress disorder suggest. Trauma symptoms resulting from adverse childhood experiences — such as abuse, neglect and household dysfunction — and other forms of developmental trauma may result in affective, somatic, attentional, behavioral or relational symptoms that, if missed, may erroneously point toward mood, anxiety or disruptive disorders. Receiving disparate, symptom-based diagnoses to account for developmental trauma reactions risks inaccurate diagnosis, polydiagnosis, pathologization of psychologically adaptive trauma responses, and fragmented, ineffective care. Ask questions about the client’s life circumstances at the time in which the client’s symptoms initially occurred. Reframe diagnostic thinking from “What’s wrong with you?” to “What happened to you?”
• Know the implications: Diagnoses carry real-world implications for clients far beyond the counseling relationship. In my own practice, I have seen diagnoses allow young people to access the supports they need, opening the door to gender-affirming care or special education services. I have also seen diagnoses create barriers for young people, including the denial of military service based solely on a diagnosis received during adolescence. Examine how a particular diagnosis might affect a client’s future goals. If there is the potential that a diagnosis may help or hinder your client in the future, have conversations about the potential implications of that diagnosis with your client early and often. Approach diagnosis with care, especially with children or adolescents, or with clients from cultural backgrounds you are less familiar with.

The third set of recommendations relates to counselors’ skills in practicing diagnosis within a framework of social justice. These recommendations describe specific culturally responsive communication, evaluation and relational skills to improve conceptualization of diagnosis, particularly with marginalized clients.

• Utilize the Cultural Formulation Interview: The Cultural Formulation Interview, included in the fifth edition of the DSM, is a 16-item assessment measure that examines the impact of culture on a client’s presenting symptoms. Incorporate this tool into your standard diagnostic assessment practice.
• Utilize narrative approaches: Narrative therapy’s emphasis on externalizing, deconstructing and restorying narratives can identify the external basis of many clients’ presenting concerns, including forms of trauma and sociopolitical oppression. Think about decoloniality in your conceptualization of clients’ distress.
• Honor cultural norms and preferred modes of counseling: Accommodate cultural preferences regarding eye contact, personal space, rate of speech and inclusion of personal supports during the diagnostic process. Standard forms of “talk therapy” tend to be biased in favor of white, middle-class values. Inquire about clients’ preferences for other forms of support and treatment, including music, art, spirituality or group work.

The fourth set of recommendations relates to counselors’ actions in practicing diagnosis within a framework of social justice. These recommendations center on specific actions counselors may initiate to enact more just and equitable diagnostic practice with clients and within their communities.

• Diagnose collaboratively: Counselors are less likely to over-, under- or misdiagnose when diagnosis is discussed and assessed collaboratively with clients. Support clients’ own understanding and conceptualizations of the problems they face. Recognize that our external assessment of clients’ emotions, behaviors and presenting symptoms is incomplete without understanding the client’s own internal cognitive and sociocultural schemas. Again, think in terms of decoloniality.
• Utilize parsimony: According to the American Psychological Association, the law of parsimony states that the simplest explanation of an event or observation is often the preferred explanation. Choose the fewest distinct diagnoses that best account for the client’s presenting symptoms. For example, if a client who was previously diagnosed with posttraumatic stress disorder presents with new symptoms of anxiety or hypervigilance, consider those symptoms within the context of their existing diagnosis before adding additional diagnoses.
• Take time to conceptualize the whole person: Take time to formulate a full case conceptualization of your client, with your diagnostic impressions serving as just one source of information. Do not define a client by their diagnosis alone or refer to a client by their diagnosis. Take time to understand who your client is as a whole person before formulating a diagnosis. The developmental counseling and therapy theory advanced by Allen Ivey is invaluable for conceptualizing clients’ experiences in this way.
• Reassess previous diagnoses: Just because a client has a previous diagnosis listed in their medical record doesn’t mean it is accurate, current or beneficial. As a counselor, it is your ethical responsibility to conduct an accurate assessment with the client, using a framework of multiculturalism and social justice to inform your own diagnostic determinations. Consider whether clients’ previous diagnoses are culturally relevant, appropriate and necessary. Consult and gain collateral information from colleagues and treatment teams to inform collaborative diagnosis.

As counselors, the ability to diagnosis is a privilege we must not take lightly. The power of naming diagnoses can help or harm clients; it can allow them access to care or just as easily provide a justification for the denial of services and support. When done well, diagnosis offers clients a name to represent the psychaches they feel, a name which helps clients understand and address the problems they face. But when done poorly, diagnosis may pathologize clients’ normative attempts at coping with adversity or inappropriately blame individuals for the struggles of living in an oppressive and unjust society. We owe our clients the privilege of a just conceptualization — one that takes into account clients’ unique strengths, histories and circumstances without defaulting to the unexamined diagnoses of the DSM. Arianna and so many others deserve that from us.  

Christine Banks-VanAllen is an adjunct instructor and doctoral student in counselor education and supervision at Kent State University. She is a licensed professional clinical counselor supervisor in Ohio and is certified in eye movement desensitization and reprocessing. She has worked in a community mental health setting for the past six years and specializes in trauma treatment with adolescent girls. Her scholarly interests center on the intersections between trauma, diagnosis, adolescence and social justice. Contact her at cbanks3@kent.edu. Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.