The process of development of the DSM system of diagnosis

Please no plagiarism and make sure you are able to access all resources on your own before you bid. You need to have scholarly support for any claim of fact or recommendation regarding treatment. Grammar, Writing, and APA Format: I expect you to write professionally, which means APA format, complete sentences, proper paragraphs, and well-organized and well-documented presentation of ideas. Remember to use scholarly research from peer-reviewed articles that is current. Sources such as Wikipedia, Ask.com, PsychCentral, and similar sites are never acceptable. Each classmate’s document is attached so please respond separately.

Read your classmates’ postings. Respond to your classmates’ postings.

  • Respond to all colleagues on how to incorporate culturally sensitive practices into the diagnosis practice so that an individual or population is not marginalized intentionally or unintentionally.

1. Classmate (N. Kim)

The process of development of the DSM system of diagnosis

The many different classification systems that were developed over the past 2000 years have differed in their relative emphasis on phenomenology, etiology, and course as defining features. The various classification systems were developed over the past 2000 years including numerous diagnostic categories. Work groups that generated a large number of papers, monographs, and journal articles were formed to create a research agenda for the fifth major revision of DSM (American psychiatric association, 2013). The APA first published DSM in 1844, and it functioned as a statistical classification of mental patients (American psychiatric association, 2013). DSM was operated as an element of the full U.S. census. APA formed the DSM 5 task force to begin revising the manual as well as 13 work groups focusing on various disorder areas, and the current DSM-5 offers guidelines for diagnoses that can inform treatment and management decisions.

The development of the DSM 5

It is somewhat surprising that homosexuality was considered as a mental illness, and was de classified as a mental illness in 1973. I have quite a few friends who are LGBT, and they seem to be just like the people who are heterosexual. The reasons that homosexuality was declassified were that many homosexuals are satisfied with their sexual orientation and demonstrate no generalized impairment (Toscano & Maynard, 2014). Moreover, it is quite surprising that DSM 5 includes an updated version of the Outline, an approach to assessment using the Cultural Formulation Interview (CFI) (American psychiatric association, 2013).

How the classification system of disorders in the DSM 5 has pathologized

The DSM can be treated as a living document, changing with clinical work. Gender dysphoria can be an example of DSM being influenced by societal critics. A major problem with pathologizing gender-atypicality is that there is a lack of consensus on gender appropriateness (Langer & Marint, 2004, p12). Anyone can struggle with the life stressors when formulating a new identity. It is important for counselors to find out if the client falls under criteria for a GD diagnosis and not suffering from an intersex condition, fetishism, somatoform disorder, or other disorder (Byne et al. 2012).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Byne, W., Bradley, S.J., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., … Tompkins, D.A. (2012). Report of the American Psychiatric Association task force on treatment of gender identity disorder. Archives of Sexual Behavior, 41(4), 759–796. doi:10.1007/s10508-012-9975-x

Langer, S.J., & Martin, J.I. (2004). How dresses can make you mentally ill: Examining gender identity disorder in children. Child & Adolescent Social Work Journal, 21(1), 5–23. doi:10.1023/B:CASW.0000012346.80025.f7

Marion E. Toscano & Elizabeth Maynard (2014) Understanding the Link: “Homosexuality,” Gender Identity, and the DSM, Journal of LGBT Issues in Counseling, 8:3, 248-263, DOI: 10.1080/15538605.2014.897296

2. Classmate (L. Shave)

Mental illness and associated symptoms have been prevalent for many years. In the 1800s, in the United States, professionals identified a need to begin to quantify and classify mental health disorders and to collect and to begin to interpret statistical information. As information was collected and observed in individuals who presented with mental health symptomology, categories of disorders based on symptomology, behavior, personality, and biological factors became classified and organized in a manner to create reliable diagnoses. This led to the development of the DSM-II. The DSM-III was developed and published in 1980 with adding more specific diagnostic criteria and developing a diagnostic system of five axes.  The five axes are as follows: Axis I provides the mental health diagnosis, Axis II provides the diagnosis as to personality disorders and mental retardation (intellectual disability,) Axis III provides any medical conditions that the individual may have that can affect their mental health disorder or impact the disorder, Axis IV produces specific environmental or psychosocial stressors that the individual is experiencing at the time of diagnosis and Axis V provides a number as to the individual’s level of functioning on the Global Assessment of Functioning for an adult, or from the Children’s Global Assessment of Functioning if the individual is a child.  The updated version of the DSM was developed to provide a more definitive diagnosis and substantiating the diagnostic criteria. The DSM-IV was published in 1994 after finding that the DSM-III demonstrated that some of the diagnostic information was not clear. This version of the DSM was developed with having mental health professionals and organizations review the literature and establish a firmer and more concrete basis to substantiate the changes. The DSM-5 was published in 2013 after many experts around the world created the manual based on evidenced-based findings to improve the ability to diagnose individuals and to facilitate treatment services in a variety of settings.

Based on the history of the development of the DSM and intermittent updates as to the information provided in this manual until the most recently published of the DSM-5, I learned that the complexity of providing accurate diagnostics to be quite a challenge. Even though there have been revisions, I believe that in the future, there will be continued revisions indicated due to the complexity of an individual,  the environment that surrounds the individual and the changes that continue to occur in this country and around the world. Based on multiple factors that are difficult to take into account at the time of the development of the DSM-5, since that time, and in the future, there are other issues or potential effects that have not been fully explored or researched. Some of these factors include cultural issues, biological and neurological factors, and unpredictable events that can arise and continue to impact others.

One example of how the classification system of mental disorders has pathologized individuals with mental health issues remains the stigma attached to mental illness. There have been improvements with educating the general public at a local level and throughout the country with the use of education, however, the stigma associated with mental disorders remains evident and remains a barrier for individuals seeking treatment, leading to feeling a sense of shame, and being focused on by others, whether it be family or individuals in the community. People seem to lack the insight that a mental health diagnosis is something that can be treated successfully and that a mental health diagnosis is not necessarily a life-long label that an individual possesses. When an individual has a mental health diagnosis, the illness is a part of the person and not the entire person. In addition, a mental health diagnosis can change over time and have a sense of fluidity.

3. Classmate (T. Roberts)

Main Discussion Post

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association [APA], 2013) is the most used text for researchers and clinicians. This book was finalized and published in 2013 with about 13 work groups that focused on various disorder areas. The DSM- 5 helps determine diagnoses for people who suffer from mental disorders. Determining an accurate diagnosis is the first step toward treating a client appropriately.  It provides a common language for clinicians to communicate about their patients and establishes consistent and reliable diagnoses that can be used in the research of mental disorders. The DSM-5 also provides a common language for researchers to study the criteria for potential future revisions and to aid in the development of medications and other interventions (APA, 2013).

One thing that surprised me when it comes to the development of the DSM-5 is how many different revisions it has gone through throughout the many years it has been developed. When it comes to the DSM 5 it is clear and obvious that is an educated guess on symptoms that a person may suffer from. Not everyone is the same and will experience all or possibly none of the symptoms. This does not disqualify a client from not having the mental disorder. Another thing that surprised me is how symptoms are remarkably similar to other disorders. When it comes to diagnosing client’s, it is okay for a client to experience a symptom one week and in a month that client no longer has that same experience.

One example of how the classification system of disorders in the DSM-5 has marginalized diagnosed populations currently is because they treat some disorders as insignificant. For example, suicide is a current ongoing issue today. Suicide is not considered to be apart of the DSM-5 because many people who commit suicide do not have prior mental disorders (Oquendo & Baca-Garcia, n.d.). Although schizophrenia, alcohol use disorder or post‐traumatic stress disorder are all associated with significant risk for suicide attempt or death it is not seen as a separate diagnosis.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Oquendo, M. A., & Baca-Garcia, E. (n.d.). Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. WORLD PSYCHIATRY, 13(2), 128–130. https://doi-org.ezp.waldenulibrary.org/10.1002/wps.20116

Required Resources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

  • Section      III, “Cultural Formulation”
  • Appendix, “Glossary of Cultural Concepts of      Distress”

Kress, V. E., & Paylo, M. J. (2019). Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment (2nd ed.). New York, NY: Pearson.

  • Chapter 2, “Real World Treatment Planning:      Systems, Culture, and Ethics”

Hargett, B. (2020). Disparities in diagnoses: Considering racial and ethnic youth groups. North Carolina Medical Journal, 81(2), 126-129. doi:10.18043/ncm.81.2.126

 

Toscano, M. E., & Maynard, E. (2014). Understanding the link: “Homosexuality,” gender identity, and the DSMJournal of LGBT Issues in Counseling8(3), 248–263. doi:10.1080/15538605.2014.897296

Aftab, A. (2019). Social misuse of disorder designation, part 1: Conceptual defenses. Psychiatric Times. Retrieved from https://www.psychiatrictimes.com/dsm-5/social-misuse-disorder-designation-part-i-conceptual-defenses

American Psychiatric Association. (n.d.). DSM history. Retrieved December 10, 2019, from https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm

Spiegel, A. (2004). The dictionary of disorder: How one man revolutionized psychiatry. The New Yorker. Retrieved from https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder

Required Media

Walden University (Producer). (2019c). Social misuse of diagnosis: Pathologizing marginalized populations. Minneapolis, MN: Author.

Social Misuse of Diagnosis: Pathologizing Marginalized Populations: Candace McLain, PhD

© 2020 Walden University 1

Social Misuse of Diagnosis: Pathologizing Marginalized Populations: Candace McLain, PhD Program Transcript

[MUSIC PLAYING]

CANDACE MCLAIN: Hey everybody, Dr. Candace McClain here. I am a core faculty at Walden University in the clinical mental health program. I’m here to talk to you just for a very brief couple of moments today about avoiding pathology and diagnosis assessment and treatment planning. Part of how this came about for me was a few years ago, I really had this epiphany that all of this avoiding, pathologizing, avoiding, biases, really starts with understanding our counselor identity.

And so I think it’s important to look at, OK, what is my role and responsibility in my identity as a counselor first and foremost. And if we look at the roots of how counseling really got started, it was really based more on a developmental model, and a model of wellness and health, versus some of the other fields who were more medical model and built on diagnosing and looking for pathology. And so I think it’s important to really differentiate and understand, as counselors, our identity and how it’s different than other fields.

And really how that also dovetails in to the next topic is that our identity as counselors is crucial in understanding our own world view. Now, sometimes I’ll ask students, what’s your world view? Are you aware of your world view? And they look at me, like, what’s that? Well, we have heard that word thrown around quite a bit, worldview. But I think it’s really important that we continue to analyze, reflect, and have self awareness of what that means.

And so when we look at our own world view, we’re really looking at our values, ideas, thoughts, and beliefs about ourselves, others, and the world that we live in. And that includes the biopsychosocial cultural spiritual model as well. And so you can’t really help but when you’re analyzing and reflecting on your worldview, having some kind of self- awareness of cultural humility as well in that process. And so it often involves a lot of self reflection, introspection, but also dialogue and conversations that are very authentic and very courageous with colleagues, peers, supervisors, faculty, and even family members.

And so I think that that’s a really important piece I want to encourage everyone to look at. Ironically enough, according to the ACA Cross-Cultural Competencies and Objectives, there are three core categories that are expected of counselors in order to have these competencies related to culture and awareness. And the three sections all involve this awareness that we need to have about our attitudes and beliefs, and that’s also dispositional, right. And then also the knowledge and the skills under each area.

And the three areas ironically, like I said, are awareness of our own worldview is the first one. The second one is awareness of our client’s worldview. And the third one is

Social Misuse of Diagnosis: Pathologizing Marginalized Populations: Candace McLain, PhD

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culturally appropriate interventions and strategies. If we are indeed doing those three areas; exploring, and having self-awareness, self-understanding, courageous, authentic conversations with other people about our attitudes and beliefs, and we’re working on the knowledge and the skills, then we can prevent and avoid pathologizing in our clients.

Many years ago, I worked in residential treatment with all adolescent girls, and I was leading a transitional living workshop in which the focus was success upon transitioning from foster care or residential care onto your own as a client into the world. You know, being discharged.

And our topic for that week was actually looking at trade schools and college and how to find a career. And we got about halfway through our group, and I had one of my clients, who is Native American, Lakota, from South Dakota, and who had grown up on the reservation. She raised her hand and she asked, well what if we don’t want to go to college or a trade school? What if that’s not really defined as success in our family and to us?

And for the first time, I paused and just said, wow, you’re right. That’s a great question. And internally, went home– um, actually went after work and processed with colleagues how I felt very convicted that by assuming that this was the definition of success for all of our clients that that was very not cultural competent at all. And it was imposing our world view onto our clients. And could potentially have been damaging if we hadn’t rectified that.

In that space, I also recognized that some of the other counselors had an idea that was different. And that was, well, no, they need to do X, Y, and Z to be successful. And it’s not normal or right, if you will, if all they want to do is be an artist, or make crafts, or weave rugs. And that was very, very eye opening for me, because to see the discrepancy of how something so simple as having a blind spot of our own as counselors, and being biased, and not being aware of our world view and our clients worldview could turn into something like pathologizing our clients. It’s very scary, but also eye-opening for me.

So I think that that’s just one brief example. But I think the best way to look at it is if you’re doing, ethically, what you should be doing and following the codes, and seeking and going above and beyond those codes by looking deeper at your own personal and professional growth in dispositions, character, skills, and knowledge, then you’re going to prevent, hopefully, many of those instances of pathologizing clients.

Whether it be religion, cultural pieces of ethnicity, sexual orientation, or whatever the differences are and the diversity is, it’s our responsibility to be culturally competent and look at and have that awareness at all times. And then be challenging ourselves with collaboration and supervision. So, I hope that that’s helpful. I look forward to hearing and learning about all of your world views, and see how you guys wrestle with these things while you’re in training. It’s very exciting. Take care.

Social Misuse of Diagnosis: Pathologizing Marginalized Populations: Candace McLain, PhD

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INVITED COMMENTARY

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Racial and ethnic disparities in health care occur within broader contexts impacting the youth who present for behavioral health treatment. Clinician bias and clinical uncertainty can influence diagnostic and treatment out- comes. Behavioral health professionals should strive toward effectiveness in the delivery of culturally sensitive interven- tions to assist in health promotion with youth of color.

The National Academy of Medicine (formerly the Institute of Medicine) published a report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” that highlighted its findings and recommenda- tions on health disparities in the United States [1]. At the request of Congress, the leading committee was charged with assessing the depth of racial and ethnic differences in health care. Assessing this phenomenon, the committee sought to further understand the racial and ethnic dispari- ties gap to assist health care systems and professionals in addressing this issue. Through roundtable discussions, focus groups, and other sources of information, the National Academy of Medicine (NAM) representatives made conclu- sive findings with specific recommendations.

Although this report targeted health care at large, spe- cific attention was given to behavioral health care systems and professionals who employ their skills to identify and treat behavioral health conditions. Mental health disparities have been well documented, therefore concentrated atten- tion must be given to eliminating barriers that prevent racial and ethnic minority youth groups from reaching full poten- tial through quality treatment.

The following findings from the NAM’s report have been highlighted to frame this conversation regarding dispari- ties in diagnoses among racial and ethnic minority youth (aged 10-21) within mental and behavioral health systems: 1) “Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life”; and 2) “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare” [1].

The field of behavioral health care is primarily composed of psychiatrists, psychologists, counselors, social workers,

addiction specialists, psychiatric nurses, psychiatric phar- macists, and those who support them. Each of these groups is tasked with operating within its scope of practice, which includes diagnosing and prescribing treatment protocols that lead to mental wellness. In addition, these professionals are governed by a code of ethics or conduct that encourages consideration for cultural competence.

The United States Surgeon General produced a report, “Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health,” outlining directions toward the elimination of mental health disparities [2]. This comprehensive work set in motion considerable research that centered around access to services, treatment, and workforce challenges confronting behavioral health professionals in addressing the needs of underserved racial and ethnic groups. Within its contents emerged the influence that culture and society have on mental health, and the report gives the practitioner guidance toward addressing the needs of underserved racial and ethnic groups. Awareness of mental health disparities among underserved racial and ethnic groups is not lack- ing. However, it has been challenging to strategically con- front and address these issues across behavioral health care systems.

Disparities in Youth Diagnoses

Much of the literature regarding mental health disparities has focused primarily on adults, but there has been recogni- tion of how youth from racial and ethnic groups of color are impacted by these disparities. Youth of color are more likely to be referred to the juvenile justice system while white youth are more likely to be referred to treatment-oriented services [3]. When presenting issues are the same, behav- ioral health professionals are likely to diagnose youth of color differently than their white counterparts [4]. Existing evidence strongly supports the prevalence of ethnic dispari- ties in the diagnosis of racial and ethnic youth of color with presenting psychological issues [5]. Findings from research

Disparities in Behavioral Health Diagnoses: Considering Racial and Ethnic Youth Groups

Brenden A. Hargett

Electronically published March 2, 2020. Address correspondence to Brenden A. Hargett, One University Parkway, High Point, NC 27268 (bahargett31@gmail.com or bhargett @highpoint.edu). N C Med J. 2020;81(2):126-129. ©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved. 0029-2559/2020/81212

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done by Cummings and coauthors suggest that among adolescents who experienced a major depressive episode, African Americans, Asians, and Hispanics were less likely to receive treatment than their non-Hispanic white counter- parts [6]. This study also confirmed that underserved youth were less likely to be treated by a mental health professional or receive medication for depression [6].

African American youth have been found less likely to be diagnosed with attention-deficit/hyperactivity disorder (ADHD) than their non-Hispanic white peers [7]; however, African American youth are more likely to be diagnosed with conduct-related and behavior disorders [8] as opposed to anxiety and substance use disorders. African American male adolescents are more likely to be diagnosed with thought disorders (ie, schizophrenic disorders) but non-Hispanic white adolescents are more likely to be diagnosed with bipo- lar disorder, alcohol abuse, or major depression [4].

Hispanic youth are more likely to be diagnosed by clini- cians with anxiety, adjustment and disruptive disorders, depression, substance use disorders, and psychotic disor- ders than their non-Hispanic white peers [8, 9]. In compari- son to other underserved racial and ethnic groups, Hispanic adolescents have fewer psychiatric diagnoses; however, when receiving emergency care, they were more likely to be diagnosed with psychotic or behavioral disorders than non- Hispanic white adolescents [10].

When it comes to Asian and Pacific Islander youth, Asian youth have less chance of being diagnosed with ADHD but are more likely to receive diagnoses of disruptive behavioral disorders, substance use disorders, and psychotic disorders [9]. These youth are also less likely to be diagnosed by clini- cians with depression but more likely to be diagnosed with anxiety or adjustment disorders [7].

Lastly, Native American (American Indian) youth are less likely to be diagnosed with anxiety disorders but more likely to be diagnosed with ADHD and substance use dis- orders than non-Hispanic white youth [11]. Unfortunately, most studies of Native American youth comparing them with other underserved racial and ethnic youth groups lack a representative sample that allows for generalization. More research and study are needed to better understand the needs of Native Americans and better assist clinicians in diagnosing and addressing mental health conditions within this population.

Studies that have highlighted these disparities in rates of diagnosis must examine factors that contribute to this issue. Treatment settings, clinicians’ experiences, and diagnostic training are among the factors that may contribute to such discrepancies in diagnoses among underserved racial and ethnic youth. Clinicians treating these populations could have differing interpretations and meanings assigned to presenting issues. Misdiagnoses have been strongly asso- ciated with clinician impressions, their assessments, and the instruments used in the diagnostic procedures [12]. For many youth, diagnosis can be further complicated by

the role of caregivers (ie, parents, teachers), who are often involved in reporting symptoms to clinicians that inform their assessments [5], especially when there is conflict in symptom reports.

While these studies are alarming and concerning, they further suggest the importance of training behavioral health professionals to be effective in diagnostic and assessment skills. These clinicians must be aware of general cultural traits, adolescent culture, and challenges in society that impact underserved racial and ethnic youth. When under- served youth of color walk through the doors of mental health facilities, they bring their experiences, including microaggressions and racism toward their identity group at large.

Diagnostic Disparities

Accurate diagnoses are considered the foundation of health care treatment. If health care providers misdiagnose presenting issues or misconstrue a cluster of symptoms, it can lead to a negative prognosis and devastating outcomes. Research has emphasized disparities in diagnoses [8, 9] and cultural factors relevant to diagnosing have also been discussed in the literature [13, 5]. Cultural perspectives on diagnosing have been given by medical associations, phar- maceutical industries, and other professional organizations [14]. While this has had some attention, there has been little movement toward ensuring a common approach to diagnos- ing [13].

Behavioral health and psychiatric diagnosing encom- passes observing symptoms and behaviors through the youth’s personal history or experience while taking into consideration any biological factors [13]. Psychiatry, which offers the medical aspect of behavioral health, unlike other aspects of medicine does not rely on blood tests or labora- tory tests but on guidance from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Psychiatrists’ approach to diagnosing has evolved since the first edition of the (DSM).

Even as the DSM evolved through a logical approach across many countries, cultural factors were still omitted [13]. Upon arrival of the DSM IV, acceptance of a cultural perspective was adopted through cultural formulation and acknowledgment of culture-bound syndromes, but this was only included as an appendix in the back of the manual. Cultural formulation occurs when the clinician assesses and takes into consideration an individual’s cultural background and how it influences symptom presentation or any behav- ioral dysfunction [15]. In this process, the clinician must rec- ognize how differences impact the therapeutic relationship and how these factors impact presenting issues to ensure they objectively appraise information gathered [15].

Behavioral health care providers must be able to use cul- tural information in the context of cultural formulation guid- ance in ways that lead to more accurate diagnoses. During the clinical interview, behavioral health professionals must

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integrate knowledge and awareness of cultural experiences relevant to underserved racial and ethnic youth groups and integrate these factors into the clinical interview. Sensitivity to the youth’s background would ensure the interviewer considers the youth’s story [16] and its cultural influence on presenting symptoms.

Historical Influences

Youth of color are subjected to the history of racism in mental health and other historical barriers that have, inten- tionally and unintentionally, led to disparities in diagnosis and treatment. Regardless of the origin of disparities, behav- ioral health professionals must be aware that they exist and informed of strategies to address mental illness for youth of color. Medical research and mental health care have founda- tions of racist behavior that still permeate throughout the health care system.

Samuel Cartwright, MD, can be identified as responsible for playing a role in misdiagnosis among underserved racial and ethnic groups. In the 19th century, Cartwright coined the term “drapetomania” to ascribe mental illness to African slaves who sought to escape and not conform to the institu- tion of slavery [17]. His work was accepted and published in medical journals and was embedded into the culture of that day, laying the foundation for other publications to follow.

Cultural and racial differences in mental health care have been misunderstood over the years and have been positively correlated with overdiagnosis of mental disorders and likely contributed to misdiagnoses as well [17]. Misdiagnoses of mental health problems among underserved racial and ethnic youth groups lead to improper care and treatment [5]. Research has suggested some differences in diagnoses among underserved youth groups centered around inter- view format (structured versus unstructured), culture and language, and interpretation of symptoms [18]. When clini- cians are familiar with these factors and take them into con- sideration, they can more accurately confirm diagnoses and ultimately initiate accurate treatment plans that will lead to positive outcomes among underserved racial and ethnic youth groups. This effort can be more unvaryingly applied through shifting of cultural competency knowledge into cul- turally proficient methods.

Cultural Competence and Proficiency

Cultural competency, “a set of behaviors, attitudes, and policies that come together to work effectively in cross-cul- tural situations,” has been emphasized across many profes- sional sectors of our society, especially in health care [19]. While the term receives much attention and focus, behav- ioral health professional organizations have been limited in assisting their membership toward obtaining proficiency of skills. Cultural competency has been expanded to include attaining the knowledge, skills, and attitudes to provide effective care for diverse populations and suggests provid- ers utilize culturally competent knowledge and skills that are

compatible with those served [20]. These definitions alone are inclusive and describe what cultural competency should be, but fail to describe methods or practices to ensure pro- fessionals become proficient in applying this knowledge to the lives of those served, commingled with their training in addressing mental health conditions.

How professional groups are trained in cultural compe- tency can determine their consideration for racial and ethnic differences when a person of color presents for treatment. Therefore, competence and proficiencies related to the cultural experiences of underrepresented groups are para- mount to successful treatment engagement and success. Behavioral health professionals must be sensitive to the intersections of race, ethnicity, and treatment issues with consideration for how these factors align with their profes- sional training. It is important to note the difference between cultural competency and cultural proficiency. Academic training should include preparing professionals for encoun- ters with those who are culturally different from themselves. Academic programs often highlight the need to recognize differences and accept these differences without allowing personal bias and preconceived notions to impact service delivery (competence). Students and professionals should be made aware of how these differences affect present- ing issues; however, we must also know how to effectively intervene with sensitivity and employ treatment protocols that lend to successful outcomes of treatment (proficiency). Learning how to employ skills or knowledge in consideration of one’s personal attitudes will begin to reduce the dispro- portionality of diagnoses among youth of color.

Conclusion

North Carolina’s public behavioral health profession- als are challenged to treat very complex issues of persons who present for treatment for mental health, substance use, and/or developmental disabilities. This complexity is often layered with social, economic, educational, physical health, and family issues in a transforming mental health system. These factors further complicate progression toward well- ness. Behavioral health professionals typically only see a glimpse of how these complexities are interrelated and influ- ence presenting symptoms for treatment. Considering this, behavioral health professionals at large have done a great job addressing and preventing debilitating issues and, in many instances, death.

As our society becomes more global and evidence-based, it will be important for institutions of higher education and professional schools to ensure their students are prepared to address the needs of underserved racial and ethnic youth, and that effective methods of treatment are consistently employed through cultural proficiency and skill. This begins with awareness and commitment to accessing all available resources while living up to our ethical codes and responsi- bilities as professionals. Underserved racial and ethnic youth are due the best available services. It has been the intent of

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this review to renew our commitment and service to those youth of color who have traditionally been underserved and retool our skills toward improving their outcomes toward wellness.

Brenden A. Hargett, PhD, LCMHC, LCAS, NCC licensed clinical coun- selor and licensed clinical addiction specialist, High Point University, One University Parkway, High Point, North Carolina.

Acknowledgments Potential conflicts of interest. B.A.H. has no relevant conflicts of

interest.

References 1. Smedley BD, Stith AY, Nelson AR, Institute of Medicine (US) Com-

mittee on Understanding and Eliminating Racial and Ethnic Dispari- ties in Health Care, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Acad- emies Press; 2003.

2. Office of the Surgeon General (US), Center for Mental Health Ser- vices (US), National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Re- port of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2001.

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