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Schizophrenia began to be over-diagnosed in the Black community in the mid-twentieth century.

Mischaracterization of Black mental health clients as aggressive or dangerous complicates pathways to care.

Psychologists can self-reflect to help reduce racial bias in diagnosis and care.

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.

He focused his account on the evolution of diagnostics in a particular hospital in Michigan, but the themes he presented applied far and wide in not only the healthcare system, but also the media and public eye. Since the publication of this book, research has continued to bolster evidence of historical and present-day bias for overdiagnosis of psychosis in Black individuals, societal and internalized stigma regarding psychosis, and significant differences in access to and use of mental health treatment. What do we know about the impact of these biases, and what can we do to address them?

How Diagnostic Bias Took Hold—and Still Lingers

The overdiagnosis of schizophrenia and other forms of psychosis in Black individuals was not limited to the civil rights movement. Perceptions of Black individuals as “mad” rather than “sad” or “paranoid” rather than “afraid” may stem from civil rights era shifts towards viewing psychosis as a Black disease, but they continue even now to contribute to the racial gap seen in the rate of diagnosed psychosis (Faber et al., 2023).

The Treatment Gap After Diagnosis

Even when diagnoses are appropriately made, and a Black individual truly experiences psychosis, treatment options may differ widely. A study in 2023 found that even when adjusting for other non-race factors (including socioeconomic status), Black individuals with schizophrenia are “significantly less likely to receive any mental health treatment” (Bommersbach et al., 2023).

Being let down by the system in such a fundamental way can lead to further social challenges that compound both the symptoms experienced by the individual and the stigma held by the community. A vicious cycle is perpetuated, in which something as simple as language (e.g., “paranoid” rather than “afraid”) contributes to misdiagnosis, mistreatment, and missed opportunities to focus on healing; and societal problems as unsavory as racism and discrimination continue to permeate medicine and the healthcare system.

Stigma Within Communities and Institutions

Within Black communities, individuals experiencing or with a diagnosis of psychosis spectrum disorders face similar and additional challenges regarding this label. A systematic review conducted in 2021 found that the path to psychosis treatment for Black individuals is “more traumatic and less straightforward” than for individuals of other races (Oluwoye et al., 2021). These researchers and others have pointed to the influence of systemic factors, as described above, and individual and community factors, particularly related to stigma. Even putting aside stigma from the healthcare system and the media, stigma surrounding mental health has long been prevalent in Black communities (e.g., biases against receiving mental health care in favor of a focus on spiritual connection). The compounding challenges of stigma and stereotyping from society, one’s community, and oneself make for a perfect storm of misaligned, delayed, or absent mental health care.

What We Can Do Differently

The first step towards making changes in a problematic system is acknowledging that the problem exists. As providers and individuals, we must engage in self-reflection that can be uncomfortable, but is essential.

Following a 2001 report by the Surgeon General on mental health disparities, a 2003 paper outlined the ways that bias specifically contributes to these disparities (Snowden 2003). Having been cited over 500 times, the message was clearly received: Bias in medicine is a problem that needs addressing. However, these disparities still exist (e.g., Shea et al., 2022).

Find a therapist to treat psychosis

To address this, we as psychologists can ask ourselves questions such as the following before assigning a diagnosis to any client:

Have I considered cultural factors (e.g., spirituality) in my characterization of this individual’s symptoms?

Have I considered cultural history (e.g., historical mistreatment of individuals of a similar background) in my understanding of this individual’s response to me?

Have I made assumptions about this individual’s presentation based on secondary information (e.g., a previous report that described an individual who asked about the provider’s credentials as “paranoid”)?

The recognition that we have erred in one or more of these areas does not in itself make us a “bad” or “racist” provider. Assumptions such as these are not new and often are not intentional. What is intentional, however, is what we choose to do next. If we use a standardized assessment or interview, we can ask follow-up questions when certain responses are given. For instance, if an individual endorses a belief that “people are always watching me,” we can ask for examples, which may reveal that they experience this feeling of surveillance when they browse higher-end stores (an experience of being watched that, unfortunately, often happens to Black individuals) but at no other times.

Beyond assessment, psychologists have an obligation to address the language we use when documenting interactions with our clients. Have we described an individual as “guarded” when we have not been transparent with them about their diagnosis? Have we described them as “aggressive” when they have raised their voice when recounting a frustrating experience? Would we describe their behaviors the same way if they were of a different racial background? By being mindful of our language, we can minimize assumptions that stem from so many years of bias and maximize accuracy in recounting client interactions.

These are only a few small shifts in thinking that we can enact in our work. In addition, we can consider our roles in the larger system—educate ourselves, encourage our medical and healthcare colleagues in all fields to engage in similar self-reflection, and engage with leaders and change-makers about issues of health disparities. Big or small, every step counts in moving us closer to true health equity.

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Bommersbach, T. J., Rhee, T. G., Stefanovics, E. A., & Rosenheck, R. A. (2023). Comparison of black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use. Schizophrenia Research, 253, 22-29.

Faber, S. C., Khanna Roy, A., Michaels, T. I., & Williams, M. T. (2023). The weaponization of medicine: Early psychosis in the Black community and the need for racially informed mental healthcare. Frontiers in Psychiatry, 14, 1098292.

Metzl, J. M. (2010). The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon Press.

Oluwoye, O., Davis, B., Kuhney, F. S., & Anglin, D. M. (2021). Systematic review of pathways to care in the US for Black individuals with early psychosis. NPJ Schizophrenia, 7(1), 58.

Shea, T., Dotson, S., Tyree, G., Ogbu-Nwobodo, L., Beck, S., & Shtasel, D. (2022). Racial and ethnic inequities in inpatient psychiatric civil commitment. Psychiatric Services, 73, 1322-1329.

Snowden, L. R. (2003). Bias in mental health assessment and intervention: Theory and evidence. American Journal of Public Health, 93(2), 239-243.

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