Date of Award

Summer 2011

Document Type


Degree Name

Doctor of Philosophy (PhD)


Counseling & Human Services


Counselor Education and Supervision

Committee Director

Danica G. Hays

Committee Member

Christine Ward

Committee Member

Jill C. Dustin


As the U.S. population continues to diversify, counselors are challenged to respond to the interface of culture and mental health concerns of clients (Gushue, Constantine, & Sciarra, 2008). It is important for counselors when making clinical decisions to reflect on the diverse needs of clients as well as the potential impact of cultural factors on mental health (Sue & Sue, 2008). Accordingly, this study sought to investigate the clinical decision-making process among counselors and counselor trainees and how, if at all, cultural factors influence the case conceptualization of clients. The study also investigated how counselors and counselor trainees collect and process client data when making clinical decisions to include: diagnostic decisions, current level of functioning, and prognosis. The concurrent mixed methods study tests and revises a grounded theory of clinical decision-making and degree of match between counselors, counselor trainees, and clients (Hays, McLeod, & Prosek, 2009; Hays, Prosek, & McLeod, 2010).

Participants viewed 1 of 6 mock client videos representing identical symptomology, but differing on cultural variables of race/ethnicity and gender. After viewing the video, participants diagnosed the client and completed an electronic survey packet of both qualitative open-ended survey questions and quantitative survey instruments. Demographic information was collected from participants to determine degree of cultural match with client.

Results indicate counselors and counselor trainees arrive at different diagnostic decisions when provided identical clinical data. However, counselors and counselor trainees utilize similar cognitive tools when conceptualizing information from clients. Diagnostic variance was identified to account for differences in diagnoses. Cultural factors such as race/ethnicity and gender are considered within the presenting problem and/or diagnostic decision; but cultural bias also influences the clinical decision-making process. There is a statistically significant relationship between the degree of racial/ethnic match between counselor/counselor trainee and client and the consideration of race/ethnicity in the presenting problem and/or diagnostic decision. However, there was no statistically significant relationship between the degree of gender match between counselor/counselor trainee and client and the consideration of gender in the presenting problem and/or diagnostic decision. Lastly, there were no statistically significant relationships between cultural bias and perceptions of client functioning; although the small sample size limits the quantitative findings of the study. The developing theory of the clinical decision-making process of counselors and counselor trainees is presented. Implications of the theory for counselor educators and future research are discussed.


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