Mental Health in Black and White


I navigated America’s mental health system for years. While I am a trauma survivor, I had something else going on. For the first 40 years of my life I had an undiagnosed learning disability: auditory processing disorder. Auditory processing disorder or APD can have profound effects on a person’s mental health because of the obstacles to healthy interpersonal communication it presents. When you cannot properly process and respond to verbal cues, people perceive you as stupid at the worst, or very odd at the most benign. A healthy social life becomes almost impossible. To complicate things, at around age 32 I started to experience PMDD or premenstrual dysphoric disorder, which resulted in profound depression every month until I had a hysterectomy at age 39.

So, saddled with these undiagnosed disorders I made my way through the offices of countless therapists, psychologists, and psychiatrists. I presented with complaints that were sometimes labeled depression. Sometimes they were labeled anxiety. The anxiety was sometimes modified by words like generalized or social. I even got a seasonal affective disorder diagnosis thrown in for good measure. PTSD finally showed up on my diagnosis list after I was shut down and ignored for years when I tried to talk about my trauma history. But the most interesting diagnosis I was given was that of borderline personality disorder.

Prior to the onset of the PMDD, I presented to provider after provider with the same complaints. Complaints about difficulties interacting with co-workers. Complaints about my inability to speak in meetings and classrooms. Complaints about apprehension in social settings. Complaints about problems with focus and concentration. Complaints of sadness due to the existence of the other complaints. What accounted for the different diagnoses?

When I looked through my mountains of medical records, I saw that the providers who listed my race as black applied diagnoses like major depressive disorder and PTSD. The providers who saw me as white preferred diagnoses of panic disorder and borderline personality disorder.

Never did a provider ask me what my ethnic background was. They all felt comfortable guessing and reporting their guesses in my medical records.

My experiences lead me to think these providers thought that a black woman might have a reason to be upset, whereas a white woman is simply crazy.

I think many people will agree that it is hard to be a black woman in the United States. But is it so much easier to be a white woman? Apparently I’ve been both so I’ll go ahead and answer that.

The answer is: It depends. Most of my professional and academic dealings have been with white people, so I’ll talk about them. The fact that my interactions are primarily with white people is largely due to the homogenous racial makeup of Kansas. Here’s an example of how color shades my interactions, so to speak. When white people see me as white they assume I have opinions and experiences like they do. When white people see me as black it is usually because they are trying to pick a fight with me over something they saw on Fox News.

White Twilah gets, “What did you think about these current events?”

Black Twilah gets, “Why do you all always have to riot?”

White Twilah gets congratulations on her academic achievement. Black Twilah gets accusations that affirmative action gave her unearned advantages. White Twilah gets complimented on her curly hair. Black Twilah gets asked why she doesn’t straighten her locks.

White Twilah gets asked for an opinion, praised for her hard work and complimented on her appearance. Black Twilah gets asked to defend her civility, accomplishments, and personal presentation based on racial affiliation with strangers who are stereotyped on the television. As black Twilah, I’m not asked for my thoughts, I’m asked to defend my integrity. So yes, being a black woman is a bit more stressful in that regard.

Psychiatry does not exist in a vacuum impervious to the dynamics of a racist society. The dynamics I have outlined above have affected my diagnoses. Just because I have an extra layer of bullshit to deal with when I’m perceived as black doesn’t mean I don’t have enough bullshit to deal with when I’m perceived as white. I am not aware of any woman who has not dealt with gender-based harassment which ranges from inappropriate remarks, to catcalls, to threats and all the way up to rape and other physical abuse. White women are certainly not immune to the pervasive societal ills that are sexism and gender-based violence.

Let’s add another dynamic to this race and diagnosis discussion. The providers who initially dismissed me from therapy and denied I could have experienced trauma were all middle-aged white women. They had PhDs in Psychology or Masters of Social Work degrees. Their diagnoses were major depressive disorder and they refused to treat me for more than a few sessions. They all saw me as white.

I didn’t get a diagnosis of PTSD until I saw a brown-skinned psychiatrist of an ethnicity and culture unknown to me who went to medical school in Pakistan. He labeled me as African-American in my medical records. I then saw a few more providers who were originally from Middle Eastern and South Asian countries. Some of them looked a lot like me. All of the ones who labeled me African-American took my trauma seriously. Only one Middle Eastern doctor, a man from Syria who labeled me as white, diagnosed borderline personality disorder instead of PTSD or depression or both. I can’t help but wonder if their experiences as brown people in the Unites States helped them understand some of the stressors I have experienced and their effects.

Not a single practitioner of any extraction or cultural persuasion took my complaints of PMDD seriously until I found a reproductive endocrinologist on my own, with whom I started treatment. Not a single practitioner considered whether an auditory disorder that affects communication could have a role in my mood experiences. For that omission I blame them less because my APD is usually not evident in one-on-one conversations with no background noise, which is the context in which I saw all of the clinicians.

Of course, my experiences are just anecdotal. But if racial bias due to subjective experiences of practitioners can play such a large role in mental health diagnostics, how is this even considered a scientific discipline? If I had such an enormous variance of diagnoses among cardiologists that correlated with my perceived race and ethnicity, cardiology would be called into question. But in psychiatry this kind of bias is the norm, and it is accepted as such.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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Twilah Hiari
Twilah Hiari is a recovering patient with a B.A. in Philosophy. She's the author of Regression, a memoir that chronicles her medically induced descent from undiagnosed Asperger's to lower-functioning autism. She's an impassioned medical freedom advocate who supports holistic, non-coercive recovery methods for neuroimmunological conditions such as autism, PANS/PANDAS, and autoimmune encephalitis.


  1. Psychiatry does not exist in a vacuum impervious to the dynamics of a racist society.

    Maybe the understatement of the week. In fact psychiatry has been rooted in racism from it’s inception, and has always functioned to support white supremacy and to pathologize the dissatisfaction and resistance of Black people.

    All psychiatric diagnoses are oppressive, and tend to be random, so I think looking for the “right” one is a waste of time. If you think you need counseling, you can find that without psychiatry being involved.

    But if racial bias due to subjective experiences of practitioners can play such a large role in mental health diagnostics, how is this even considered a scientific discipline?

    I think you’ve sort of answered your own question. 🙂

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  2. Diagnosing can really be a crapshoot, can’t it? I just read this article that examines bias in mental Heath:

    However, to me, walking into a practitioner’s office can be this great equalizer, in the sense that no one is getting out without one. Unless you have the money to see someone under the table, and can leave insurance out of it, a diagnosis is going to be given. Maybe some are viewed as being more stigmatizing than others, and biases certainly play a hand, but you will get one none the less, it’s the nature of the beast.

    Interesting, Twilah, when you were viewed as “white”, you received the “crazy white lady” diagnosis (borderline), and that when there was racial/ cultural understanding there, it reflected in the diagnosis. Age, culture, gender, ethnic background, socioeconomic status, etc do play into it, both as the person getting “treated”, and as the “professional” doing the diagnosising. I don’t think anyone is safe from getting screwed, though. There was once this psychiatrist where I worked who was male, in his 50s, of Haitian descent, and if a white American male came to see him, it was pretty much guaranteed he wouldn’t listen. Actually, the only time I personally recall him listening and taking the patient’s opinion into account, was this young Haitian woman who came to see him. It was the only time I saw him back down. Perhaps because they were of the same ethnic origin? Not sure, but that’s how it seemed. I agree there are too many variables to take into account for diagnoses to be accurate.

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    • I paid outside my insurance for a second opinion from a psychologist, and still had the common symptoms of (a “safe smoking cessation med”) / antidepressant discontinuation syndrome, worsened by the common ADRs of a (“safe pain killer”) / dirty opioid, misdiagnosed as “bipolar.” So paying outside one’s insurance doesn’t always result in avoidance of a DSM stigmatization, and the subsequent psychiatric gas lighting.

      Twilah, lovely lyrical blog, and absolutely you are correct, all the DSM stigmatizations are unreliable. Thus, in a way, there is no black and white when it comes to DSM diagnoses. But it was an interesting read, leaving one questioning, is it worse to be a black female dealing with the bigotry of psychiatrists or a white female?

      I do love your name, best I could find, it means “and the light shinest in darkness.” I’m not sure that’s the meaning of your name. But if so, thank you for being true to your name, and shining light on this dark age of worldwide psychiatric terrorization and bigotry.

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      • I’m sorry to hear that happened to you. What I meant was, if a person has money to pay to see someone under the table, there’s the possibility that you can seek out a therapist who is willing to listen without all of that diagnosing/ medicating stuff. A person seeking “help” would still need to do their homework when trying to find someone who isn’t going to do that. They are out there, I know people who have found therapists who they pay to listen and process things with them, but who don’t mention meds or diagnoses. I do agree just because you go outside of your insurance, that in and of itself doesn’t mean you aren’t going face those kinds of things.

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  3. “When white people see me as black it is usually because they are trying to pick a fight with me over something they saw on Fox News”.

    I laughed out loud when I read that! It is SO true and so hilarious precisely *because* it’s true. The “Borderline Personality Disorder” diagnosis is second only to “Antisocial Personality Disorder” as THE most toxic psychiatric label that a Mad person can get. People who are labeled with BPD are so hated, I think, because, as a whole, they’re able to “play the games” of our sanist society for a while, even though they’re sometimes very Mad. Racial profiling in psychiatry is just one of the many ways it oppresses its victims. All psychiatric labels are as unscientific as they are unhelpful, and their industrious exploitation of every existing form of bigotry ensures that they’ll always have an excellent chance of becoming even more daft and counterproductive constructs.

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  4. Subjectivity is Psychiatry’s stock in trade. You’re lucky you weren’t perceived as a black male – you’d either have Antisocial Personality Disorder or Schizophrenia. To call psych diagnosis “racist” doesn’t begin to get at how divisive and destructive it really is.

    Thanks for sharing your experience – I’m going to keep my eyes open regarding African-American women in a different way now. (I’ve already observed that white women who are unhappy with their roles are mostly labeled “borderline” or “bipolar” or have “major depressive disorder).

    —- Steve

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    • “You’re lucky you weren’t perceived as a black male.” I SO heard that, Mr. McCrea. When dealing with Black males, psychiatry won’t usually shit around with a thoughtful and pseudo-benevolent period of control-by-advice/empty promises/concern trolling/etc. The psychiatric system pretty much just skips straight to its thug jobs on their Black male patients. And they don’t get “respectfully” brutalized like Hannibal Lecter was in “Silence of the Lambs”, either. They just get treated like apes or like the dinos in “Jurassic Park”.

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      • I remember during my second and last forced treatment there was the nicest, most peaceful, and kind, but very large black man, his name was John. We were all minding our own business, the staff provoked John for seemingly no reason. He stood up for himself, but respectfully, and peacefully. The staff attacked and force medicated him, seemingly only to terrorize the rest of us, with their unjust power. It was sick, John was a gentle giant.

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        • Is it possible this reaction could also have been because he was large in size and male? To me it seems like mental health workers in general tend to overreact with men (mobile crisis and police called), even with men who don’t have any kind of a history of violence, or over incidents that could be handled without having to do all of that. In my experience in community mental health, women were able to act out a lot more, including physically assaulting male staff members , and the male staff members were made to feel like “wimps” for speaking up for themselves, and female staff were put down for not being “strong women”, We also know statistically, young boys and men under the age of 18 are being prescribed anti- psychotics at an alarming rate, higher than girls. It’s all bad, but this idea that men/ boys, or white men/ boys are automatically “privileged”, I don’t agree. Maybe sometimes yes, but sometimes it’s no. I agree with Twilah’s above observations, that it really depends.

          Interesting video I saw recently about men and boys, and how hard our society makes it for them to seek help:

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          • Privilege is a relative thing. I agree that large males are more likely to be assumed to be aggressive, but large BLACK males are most definitely considered more dangerous. Look at the number of shootings of unarmed people by race. Unarmed black men are shot at MUCH higher rates than white. I don’t think it’s because a bunch of overtly racist police officers are out there looking for a black guy to shoot. I think it’s because they’re more likely to GENUINELY believe their lives are in danger when the person is black, regardless of any other variables.

            —- Steve

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          • Steve- the stats on that are a little confusing. When looking purely at numbers, in ten years, 2151 white people died at the hands of police, and 1130 blacks, so it’s more whites that die. However, in US, 63% of the people here are white and 12% black (not factoring in Asian or Hispanic populations) so it works out to be 1 in 60,000 whites will die at the hands of police, and 1 in 200,000 blacks. So yes, if there is police involvement, the chances of you dying in that interaction go up if you are black, but whites don’t get off scot free from shootings or death like our media would lead us to believe. Not really sure what the details were of the intervention with the kind, peaceful black man, I’m sure all sorts of variables factored in, but we don’t know. If the staff were provoking him, who knows what was going on there. It’s possible they were scared of him, but it doesn’t sound like it from the way the incident was described, it sounds like the staff were just provoking him & making an example out of him, and being jerks.

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      • I’m a little confused — how do you account for different people perceiving you differently, i.e. as “white” or “Black”? Is there a pattern involved in terms of what categories of people see you one way vs. the other?

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        • Great question oldhead. Excellent question actually. Too complex to answer here with any degree of completeness. I think it has a lot to do with peoples’ assumptions about phenotypes and speech. Like most outdoorsy people, my skin is darker in the summer. I noticed a seasonal correlation to a certain degree. Then there is my speech, which is closer to “standard American English” than an African American dialect. Funny to me though is how audiologists identify my speech as an “otitis media dialect” because my pronunciation of certain sounds is softened in correlation to how I learned language through fluid filled ears as a small child.
          What it boils down to though, is people have expectations of what black looks and acts like and what white looks and acts like. To specific people at specific times I resembled one more than the other. And rather than ask me how I identify myself, all of these practitioners were comfortable enough with their assumption to put it in my medical records.

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      • We used to see “Conduct Disorder” diagnosed in foster youth for a lot of teens who acted out. There was a 95% chance anyone with a “Conduct Disorder” was black, and probably a 90% chance they were male. It’s fallen out of use because of it’s loadedness and an improving awareness of bias in the child welfare community, but there was a time in the not-too-distant past where someone would say, “He’s got a conduct disorder diagnosis” and I’d say, “Oh, you mean he’s black?” I don’t think I was ever wrong when I asked that.

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  5. Twilah,

    Thank you for your most insightful article. I am sorry you’ve had to go through so much, the racism, and the medical issues. But I’m glad you’ve made it and that you’re able to take care of your own affairs and stand up for yourself.

    Some have said that for psychotherapy, you must have a therapist of your same ethnic group, and probably of your own gender too. Your article further convinces me of this. Well I should say that I would be convinced of this, if I supported psychotherapy. I don’t. So what your article shows me is that the idea that psychotherapy or medical care are neutral or objective is non-sense.

    As you pointed out, it has long been known that black males are the ones who have gotten it the worst with psychiatric diagnoses. Lots of books about this exact subject.

    As I see it, we all live in the shadow of the idealization of The Family. And this means the financially secure middle-class family of the dominant racial group. This is held up as the ideal, and some are favored by it. So following ancient custom I refer to such as First Borns.

    But if someone grew up poor, or in an immigrant or minority group, then such an ideal was out of reach. So they are more likely than not to see their own family members as working in solidarity with them, in a world which can be quite unfair.

    Whereas for those who were of the dominant racial group and not especially financially challenged, they are more likely to see the exploitation and hypocrisy they were subjected to as coming from the family.

    So when I talk about The Family, or The Middle-Class Family, I don’t necessarily mean your family or mine. People have different relations to The Family, and so they see the situation differently.

    But one thing never changes, some people are legitimated and some are not. And this is what I really see in your article.

    So here where I live we have people who are in and out of the mental health system and in and out of jail, and often kept loaded up with psych meds, and sometimes living under bridges. And then others just prescribe ethanol and street narcotics for themselves. And then they are subjected to the Evangelical message, that it is all their fault and all they have to do is admit it, and Jesus will give them a second chance. And so those with the least to lose in our society, the ones who should be the most radical, are neutralized as a political force.

    And then there are those, rather well-off, who might not feel so good, and so they go to the yellow pages and find a psychotherapist. That therapist offers them absolutely nothing at all, he just lets them talk themselves out, and then he tells them all the reasons to exonerate all perpetrators. It is not quite Freud, as in the US it is Ego Psychology. But it still amounts to making the client ( patient ) believe that the main problem is in their own head. Enough of this could drive anybody crazy. And it could go to psych meds, if they are receptive to this.

    And so how are we going to stop the dispensing of psych meds when so many people still believe that people are in need of psychotherapy? I think this is a big part of the problem. I don’t see how one can be effective in fighting against psych meds and involuntary treatment, if one still believes that some people need to be handled by a psychotherapist.

    The sorts of things you are talking about are in a grey zone, the perception of discomfort and difficulties in learning situations. How these should be looked at and what might be done, at least to me, seem unclear. But then the medical people are making the confusion more, not less.

    As I see it, The Family is a system based on finding defect, on extensions of Original Sin, because this is what Capitalism depends upon in order to gain compliance.

    So if you have parents and adult children going to doctors, then this quest will continue in full force. Whereas, I think most of it is unnecessary. We just need to understand that everyone is unique. Back off on trying to fix people or make people measure up to senseless standards.

    I am convinced that conventional school only works for a small portion of the population anyway. And what it does is turn Einstein’s, Mozart’s, Andy Warhol’s, and Elon Musk’s into Homer Simpson.

    One person of note who approaches some of this a bit differently is the writer Alice Walker, a black woman who does not present black families or black churches in a particularly flattering way. And she was very angry about Sentimentalist Spielberg taking such liberties with The Color Purple, inventing a softer side to Mister, and the reconciliation between Shug Avery and her Minister Father.

    And Walker is really smart too, as the story stops right the year before she was born, so people can’t take it as autobiographical and can’t use it to direct pity at her.

    And then here on the ground I am engaged trying to take down a corrupt, all White, all First Born’s, city administration. One of the people says she admired Nancy Reagan. She must not have read Patty’s book.

    They are all slick conformist manipulators, every one of them. But someone is starting to shed some light, and so these people are going to melt, like wax placed near a fire.

    I think we need to expose the fraud and abuse that psychotherapy, recovery, and psychiatry are, and then seek and obtain justice for childhood abuses and the unfairness of our world. People are not innately defective and don’t need to be psychically maimed to be made submissive. And so when someone is doing this, there must be public consequences.

    Usually it is White people who go along with Libertarianism, coercive conformity packaged as individualism. And this is because it is built around the image of a middle-class financially solvent white male, and this is further built out of the middle-class family.

    All I can say is that we have to take this down. So it is essential that people rise up, and I do see the difficult work you are doing as part of this.

    My own interest is in going after the middle-class family itself, and I see this as coming through lawsuits and anti-disinheritance laws, and then direct attacks on Capitalism via demands for Citizenship Pay instead of welfare and disability money, and then zero tolerance for anything like psychotherapy, psychiatry, or recovery.

    I think we have to form our own communities too. Capitalism is not the best way to spur technological or cultural creativity, not at all, and this has long been known.

    We should make our own communities and then our own Foster Care group homes, and then take in the homeless, the addicts, and the supposedly mentally ill, and then the convicts and the parolees. We should take in everyone who is not loyal to that favored First Born group, and then strike back!

    If we let ourselves be forced into Live and Let Live, then we are still in denial.


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    • I think you’re onto something there, Nomadic. When I was a kid, one of the biggest reasons I felt profoundly sad and lonely around the winter holidays was this constant stream of Norman Rockwell happy family imagery that the advertisers bombard us with, and how my own family did not measure up. The ramped-up nostalgia caused a deep longing to recapture a family dynamic that had never been real in my family in the first place.

      I love how you envision an inclusive community at the end, where no group is “othered.” Count me in.
      Blessed Be the Revolution!

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      • When I worked at the community crisis line years ago, there was always a huge surge in suicidal behavior and thinking after the holidays. Expectations almost always fell short of reality and people were reminded by too much time with their families that they weren’t a part of the Norman Rockwell image that we’re all “supposed to” experience.

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    • I would be one who you would consider to be of the “first born,” but I’m quite certain it is not the middle class white families responsible for the problems. Our children are being raped, and we’re being psychiatrically defamed, drugged, ripped apart, and stolen from now. It is the ultra rich who are to blame, not the middle class families.

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  6. Yes, a huge amount of the material directed at children amounts to teaching familyism. You see it in the kiddie books, and you see it on television.

    One thing which used to be different was Sesame Street. But in more recent decades there have been conservatizing influences, and so now it too teaches familyism to children.

    And today, much of what therapy amounts to is your therapist instructing you in the new terminologies, from the new pedagogy manuals, like attachment, nurturing, empathy, and communications skills. So once properly instructed, then you too can get down on your knees, and just like everyone else, worship the Holy Family, and be pronounced as healed.

    People have written about how horrid Foster Care is, and how high a percentage of the kids are kept on control drugs. I think the ones who get the worst of it are probably those in the Group Homes.

    Well why is it so bad? I say it is because if it were any better, it would become a threat to The Family. Capitalism depends upon being able to enforce The Family, otherwise it has no means by which to control people. So Foster Care, and especially the Group Homes, are made horrible on purpose. They are teaching kids that they are disadvantaged, and then proving it. I know that a high percentage of the kids from the group homes end up homeless.

    Suppose they started teaching kids that they were the most priviledged, realitive to this backwords world most of us live in. And suppose their was a post 18yo program, and an adult commune behind all of it?

    How good could a Foster Care Group Home be? Maybe if we ran one we could graduate the next Maximilien Robespierre and a revolutionary vanguard.

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    • As a man who works in the foster care system as an advocate, I have observed that there is another factor at work. Kids who have parents who care for them are much more willing to have their parents or guardians ask questions and challenge authorities who are trying to drug kids into submission. The real problem is that the treatment staff don’t really empathize with the kids in their care. They believe they are “helping” by “calming down” kids or “helping them learn emotional regulation” or “setting appropriate boundaries” when they are, in fact, behaving oppressively. Most workers in such places (and I used to be one) have almost no training and are not required to have done their own therapy, so they’re making it up as they go and/or responding to the pre-existing “structure,” which is often a culture of disrespect and aggression toward the youth. The staff are protected at every turn – they can put hands on a youth and physically redirect them, but if the youth fights back, the youth gets in trouble for “assaulting” them and can sometimes even have criminal charges filed, while the staff have an automatic protection against any lawsuit for that kind of event. In other words, the kids have zero power and any staff person who is untrained or unhealthy enough to act out against them can pretty much get away with it unless called on it by other staff.

      So in the end, while I agree 100% that the pro-nuclear-family propaganda is thick in this country and is quite harmful, the kids who have a parent or committed parent figure do have a better chance of avoiding drugging. In the 2009 GAO survey of foster youth and “medication,” they found that kids in stranger foster care had 4-5 times higher rates of drugging than the general population, but kids placed with relatives had only slightly higher rates of psych drug use. The difference, I think, is that the relatives were more likely to actually see the kids as people and to advocate against drugging them until other things have been tried. I think relatives are also more likely to tolerate annoying behavior as just being part of their personalities, whereas institutions want kids to be convenient and are willing to use any means, including drugs, to make them more manageable.

      —- Steve

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