Review: “(Mis)Diagnosed: How Bias Distorts Our Perception of Mental Health”

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Who we are isn’t always how we’re seen by society. What we need isn’t always what we’re given. And when it comes to psychiatric diagnoses, how we’re labeled can be stained and shaped by prejudice—reflecting systemic cultural biases that ignore trauma, diminish populations, and invalidate their humanity and experience.

That’s the essence of (Mis)Diagnosed: How Bias Distorts Our Perception of Mental Health, Jonathan Foiles’ beautifully concise and breathtakingly persuasive look at psychiatric history through the lens of human rights. In straightforward, powerful language, he looks at the present in the context of the past, highlighting links between the outmoded, outrageously bigoted diagnoses of yore with the struggles of people in the system today.

Cover of "(Mis)diagnosed"

People of color, poor people, gay people, trans people, people with developmental disabilities, women and others have been subject to discriminatory labeling and categorization—their identities cast as less-than, their experiences branded as illness. As the author repeatedly points out, our understanding of science in all its facets evolves over time. With it, our conception of the mind evolves; and with that, our ideas of disorder evolve, too. The problem lies in the cultural attitudes influencing our conceptions of all three—and while that’s obvious enough to those already questioning the current disease paradigm, Foiles has a gift for boiling it down in graspable lay terms with irrefutable logic.

Consider, for a start, drapetomania, a 19th-century label pushed by the American physician Samuel Cartwright that “explained” why Black people sought freedom from enslavement. No, it’s not because they were oppressed. “Enslaved persons did not seek to run away because of the brutality of the slavery economy but because they were mentally ill,” he writes, “just as a century later Black people protested Jim Crow not to fight for their rights but because they were psychotic.”

Once again, they weren’t oppressed; they were delusional. That belief “both allowed whites to disregard anything that Black Americans might say, since it was evidence of their shattered thinking, and institutionalize those who did speak up or revolt. Label someone’s thoughts as delusional,” he says, “and you ensure that neither you nor anyone else have to take them seriously.”

And to this day, “Black Americans—and Black males, in particular—are far more likely to be diagnosed with schizophrenia as compared with patients of other races.” When Black Americans are prescribed medication, they’re six times more likely to be prescribed first-generation antipsychotics than the less-risky meds more often prescribed for whites. They’re also more likely to receive coercive treatments.

So while drapetomania may be a relic, other prejudice-driven diagnoses and practices are not. Disparities in healthcare are not. The tendency to diagnose along racial lines is not.

Foiles uses this type of parallel vision—one eye on the past, one on the present—to unpack other biases in contemporary psychiatric treatment and their roots in longstanding social inequity. He looks at definitions and diagnoses of homosexuality over the years, including Richard von Krafft-Ebing’s late-19th century Psychopathia Sexualis—which declared it a form of degeneracy—and the inclusion of homosexuality as a mental disorder, until 1973, in the Diagnostic and Statistical Manual.

He looks at the experiences of women diagnosed with hysteria (“wandering womb”) in a previous era and borderline personality disorder in the current one, and all the patriarchal stereotypes of femininity (think Fatal Attraction) that pervade pop culture.

He looks at 19th-century “Americanitis,” at “disorders of privilege,” and at the race and class disparities between white children diagnosed with ADHD and Black children diagnosed with oppositional defiance disorder—another 21st-century heir to drapetomania.

He looks, as well, at the history of post-traumatic stress disorder and its present criteria for diagnosis, which assumes “that one has a relatively stable and harmonious picture of the world that is shattered by a horrific event: a car crash, a sexual assault, the murder of a loved one. . . . They fail to fully capture the reality for those that never had such a rosy view of the world in the first place, however.”

Foiles, a therapist based in Chicago, last explored such topics in 2019’s This City is Killing Me: Community Trauma and Toxic Stress in Urban America. His views are rooted in his real-world interactions with people in distress, which informs both his grasp of history and his empathy for those ill-served by its impact.

Sprinkled throughout “(Mis)Diagnosed” are insights from sessions with his own clients over the years, who appear in small, humanizing snippets that bring a piece of his argument to life. He also pulls insights from medical diagnoses in general, using them to draw out problems with psychiatry’s narrow fixation on the person, not the community. Lung cancer, for instance: Public health campaigns discourage smoking on billboards in low-income areas. But what about the major polluters nearby? What about other carcinogens? In the same way, he argues, environments can be toxic for mental health.

“Growing up in a safe environment with adequate resources and without being discriminated against provides a strong buffer against mental anguish,” he states. “Yet we almost never frame mental illness in terms of the conditions of our society, preferring instead to focus upon the individual and, perhaps, their immediate family.”

In this and other sections of “(Mis)Diagnosed,” Foiles’ arguments unfold with an of-course obviousness: Of course diagnoses reflect the thinking, the “science,” the prejudices of the era that hatched them. Of course such thinking changes over time as our understanding morphs. Of course this implies that diagnoses are not ironclad and precise but squishy and inexact, mere shots in the dark at comprehending the human mind and all that shapes it.

But all of this is only obvious because he links it together so deftly. And it’s only obvious because he’s open to seeing the wider arc—observing history and its effects on the present, challenging the ways people’s lives are categorized and medicalized, disparaged and dismissed.

“There is a certain amount of humility that is necessary here, a humility often lacking when it comes to the creation of the disordered,” he writes. “We felt quite certain that Black Americans had no real reasons to resist the various manifestations of white supremacy, so we determined that it was instead an expression of their paranoia. Women had no reason to complain and try to assert their voices against an often-hostile medical establishment, so they must just be hysterical. When we examine the history, these oversights leap out at us, yet we often fail to approach our current formulations with the same amount of skepticism.”

To be sure, his account isn’t exhaustive. Foiles doesn’t explore every avenue as fully as some might hope. In his diagnostic history of intellectual disabilities and the eugenics movement, he challenges our cultural obsession with IQ and questions our strict definitions of “intelligence”—calling, once again, for more inclusion. He notes that the DSM, while revising and righting some past wrongs, “does not go far enough.” But he also fails to ask why IDD is still included in the DSM at all. Why are developmentally disabled people diagnosed as mentally ill simply for existing? Why are so many of them prescribed antipsychotics? Questions, perhaps, for another book.

In the meantime, this one is plenty informative and plenty gripping—all the more so for its non-academic language and piercing brevity. If his rapid sweep through history and its ripples into the present miss a few points, he’s nevertheless looking with care and listening for voices too often ignored.

And listening, in his line of work, is everything.

That’s one of his problems with diagnosis, which “too often shapes how we listen to the person sitting in front of us.” Whatever they say winds up confirming however they’re labeled. And any given diagnosis, as he explains early on, “is just a series of words created by medical professionals to better communicate with one another.”

Sometimes people find comfort in such words, sometimes affirmation; quite often, they find pain. Either way, he says at the outset, “Perhaps it’s time to rethink the utility of those labels, or at least how we relate to them.”

Rather than reducing everyone to their symptoms, rather than overlooking all that happened in the course of their lives, rather than dismissing the role of poverty, prejudice, and systemic oppression in all its forms—rather than all of that, he asks, “What if it was possible to both acknowledge their suffering while also condemning the injustices and inequalities that have helped lead them here? That is the task that I have set for myself.”

Foiles states his case in the pages that follow, and it’s a convincing one. Let’s hope those with power start listening, too.

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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.

4 COMMENTS

  1. Hi Amy.

    I myself have used the exact same arguments against psychiatrists since I was first diagnosed in 2014 among many others.

    They don’t listen. They say I am suffering from grandiosity because I’m deluded into believing that I know more than them.

    Also I’m grandiose for other reasons I’ve been told.

    Such as the fact myself and a lady of higher social status than me fell in love 11 years ago. It went nowhere because I cut all contact with her to protect her. Not exactly mentally ill obsessive is it?

    Like I said to the psychiatrist:

    “You only think its grandiose because for some mad reason you place importance on a persons status. I don’t see it that way neither did the lady. She loved that about me. She spent far too long dealing with men with their head up their own rear. I was a breath of fresh air to her and for her part she was glad to finally let her hair down, smoke and swear like a docker. You shouldn’t judge people based on your subjective viewpoint man.” ( The lady was from a similar background to myself initially, she simply was successful beyond her peer group. )

    He said to me “You keep bringing her up.” I replied “You asked me what part of my ‘delusion’ I didnt believe was a delusion knowing one of the main ones you claim to have never happened was her even though you weren’t there and didn’t meet me for another decade. God complex much? You knew I’d bring her up.” Im over her years but the ‘doctors’ wont leave her in the past not me. Manipulative biased fool that he was. Then I told him “Look man, I know you have a limited understanding of the human mind. ( I was giving him a compliment. He actually knows nothing. ) Can’t you use that to think outside the box?” He looked away offended in a ‘Who does he think he is?’ kind of way. Yet…who does he think HE is?! I’m grandiose because I claim to know more about my own mind than he does! Lol He displayed a complete lack of insight. Madness.

    He’s completely incapable of lateral thinking. Gets paid way too much to be anything other than pedantically mediocre or perhaps isn’t bright enough too?

    I can’t see anyone changing average psychiatrists minds myself Amy. That’s why they all need to be ejected and sent to work in a factory where their linear thinking will benefit society IMO.

  2. Oh and to clarify…I’ve worked on many many a factory floor in my youth and, indeed, am not in the rarified air of psychiatrists presently so I wasn’t being disparaging towards factory workers.

    Many are highly skilled such as at an engineering company I worked at. Yet many a year ago I was frustrated bagging potatoes for supermarkets all day when I knew my capabilities and ambitions went far beyond it just as many other factory workers are.

    I’m simply saying let psychiatrists bag the potatoes while us underprivileged potato farm workers move on to bigger and brighter things…its only fair no?

  3. Thank you Amy for this important and informative essay; another book I have to read!

    Any diagnosis gets our attention, psychiatric diagnosis gets a slice of our Being. On a personal note, borrowing from the IQ passage and the cultural implications you mentioned; I was diagnosed with having an IQ of 86 when I was 12. 25 years later, upon telling my psychotherapist this, he was outraged, having spent considerable time and effort trying to convince me that I was “brilliant”. I know now, 50 years later, that that IQ test was administered to a prodigiously abused boy on Thorazine. I internalized that “understood” (intelligence) value for the rest of my life, despite considerable evidence to the contrary-of which the rest of my high school days spent in special education only worsened. My psychotherapist wasn’t the least bit outraged by my psychiatric betrayal, or remotely aware of the impact this drug most certainly had upon my IQ test, or that of my considerably shut-down state as a defense to my abuse while taking the dam test. My point here is that “misdiagnosis” is more often than not an act of violence, one with it’s own particular and diabolical (tragic) legacy.

  4. This is an interesting article, but, more and more, it seems that “misdiagnosis” like so many of life that remains “hidden” does not discriminate. If for any reason, you find yourself in a “mental health clinic” or in a “psychiatrist’s or therapist’s office”; you will be mis-diagnosed. It is a money game, a power and control game. It is basically evil and nefarious and affects us all, whether or not you are one the mis-diagnosed or not. Will this be the tragedy of the post WWII era ongoing into the twenty-first century? I don’t know. There are so many tragedies. Yet, it may very well be that it is the evil of psychiatry that is underpinning them all like a nefarious bridge to what some call “hell.” Thank you.

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