Addressing Racial Bias in Psychosis Diagnosis and Treatment

By Danielle Curiin, PhD, on behalf of Atlanta Behavioral Health Advocates

In 2009, Dr. Jonathan Metzl, an American psychiatrist, published a powerful deep dive into psychosis in the United States in the mid-twentieth century. This book, titled The Protest Psychosis: How Schizophrenia Became a Black Disease, revealed uncomfortable truths about how the civil rights movement and other social changes in the United States resulted in schizophrenia shifting from a diagnosis given to white women with “neurosis” to a disease characterizing “dangerous” and “violent” Black men protesting the mistreatment of minorities.

Dr. Metzl’s account focuses on the evolution of diagnostics within a Michigan hospital, yet the themes he presents reflect broader issues in the healthcare system, as well as in the media and public perception. Since the book’s publication, ongoing research has continued to underscore the evidence of historical and present-day bias in the overdiagnosis of psychosis among Black individuals, compounded by societal stigma and disparities in mental health treatment access. So, what do we truly know about the impacts of these entrenched biases, and how can we work towards redressing them?

How Diagnostic Bias Took Hold—and Still Lingers

The overdiagnosis of schizophrenia and other psychotic disorders among Black individuals isn’t just a relic of the civil rights movement’s legacy. The perception of Black individuals as “mad” rather than “sad” or “paranoid” rather than “afraid” signifies a troubling trend that has evolved across decades, continuing to fuel the racial disparities observed in diagnosed psychosis (Faber et al., 2023). This diagnostic bias doesn’t merely affect labels; it influences treatment trajectories and outcomes, leaving a tangible mark on the lives of affected individuals.

The Treatment Gap After Diagnosis

Even for those accurately diagnosed, the subsequent treatment and care received can vary dramatically. Recent research reveals a profound disparity: Black individuals diagnosed with schizophrenia are “significantly less likely to receive any mental health treatment,” even when controlling for socioeconomic status and other non-racial factors (Bommersbach et al., 2023). This gap leads to a cascade of worsening symptoms and deeper social issues, creating a vicious cycle in which language and perception—such as labeling a feeling of distrust as “paranoia”—further contribute to misdiagnoses, mistreatment, and obstacles to healing. It’s a scenario underscored by persistent racism and discrimination that impact the broader healthcare system.

Stigma Within Communities and Institutions

The stigma associated with psychosis is not just perpetuated by external factors; it thrives within Black communities as well. A systematic review from 2021 showed that the journey towards receiving treatment for psychosis can be “more traumatic and less straightforward” for Black individuals compared to individuals from other backgrounds (Oluwoye et al., 2021). This review highlighted that systemic factors—combined with deeply rooted individual and community biases—lead to compounded challenges that can deter individuals from seeking the care they need. Often, community-based stigma favors spiritual remedies instead of professional mental health care, complicating the already convoluted path to treatment.

What We Can Do Differently

Addressing these disparities begins with acknowledging their existence. Both providers and individuals must engage in uncomfortable yet necessary self-reflection. A pivotal 2001 report by the Surgeon General on mental health disparities inspired a 2003 paper that outlined the pervasive biases fueling these issues (Snowden, 2003). Cited over 500 times, the message resonated across the medical community: bias in healthcare is a systemic problem that commands urgent attention. However, significant disparities remain stubbornly entrenched (Shea et al., 2022).

As psychologists, we must critically examine our diagnostic practices. Some reflective questions to ask ourselves include:

1. Have I taken cultural factors, such as spirituality, into account when assessing this individual’s symptoms?
2. Have I considered the historical context of mistreatment for individuals of this background in understanding their responses?
3. Am I making assumptions based on secondary information, such as prior reports that label an inquiry about credentials as “paranoid”?

Recognizing potential errors in our reasoning doesn’t label us as “bad” or “racist” providers; such assumptions often originate from a larger cultural context and are not typically intentional. However, the true measure of our commitment lies in our subsequent actions. Utilizing standardized assessments or interviews allows us to ask clarifying questions. For instance, if a client expresses the belief that “people are always watching me,” we can explore further, uncovering a nuanced understanding of their experience shaped by lived realities—in some cases, reflective of societal oppression.

Beyond assessment, our documentation language plays a critical role in shaping perceptions. Are we labeling someone as “guarded” because we haven’t engaged transparently with them about their diagnosis? Are we describing behaviors as “aggressive” when a raised voice accompanies a recount of real frustrations? By remaining mindful of the terminology we utilize, we can reduce assumptions rooted in bias and enhance the accuracy of our documentation.

These shifts, though subtle, can catalyze significant changes in our approach as mental health professionals. Recognizing our roles in a broader systemic context entails engaging in ongoing education, advocating for changes that promote self-reflection among colleagues, and collaborating with leaders on initiatives that address health disparities. Whether our contributions are small or monumental, each effort takes us a step closer to achieving genuine health equity.

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