Part 2: Systemic Biases and Moving Toward Culturally Informed Assessments
In Part 1, I explored how systemic racism and racial disparities shape paranoia, particularly among Black Americans. If you missed it, I highly recommend giving it a read—it lays the foundation for what I’ll discuss here. In this second installment, I’ll focus on how systemic biases influence the diagnosis of paranoia and mental health, and why culturally informed assessments are essential for delivering care that’s not just accurate, but empathetic and effectively attuned to reality for people of color.
Systemic Biases in the Diagnosis and Treatment of Paranoia
The disparities in how paranoia is diagnosed and treated among Black Americans may stem from systemic biases in psychological assessments. While much work remains to be done in this area, research suggests that these biases are present both in research and clinical practice (Schwartz & Blankenship, 2007). Often, clinical questionnaires and psychological assessments have been normed and validated—meaning they were tested for reliability and accuracy—primarily within predominantly White undergraduate institutions (Cicero & Ruggero, 2021). As a result, these tools may not fully capture the lived experiences of more diverse populations.
Although these assessments are often described as “color-blind”—implying universal applicability—in reality, their development within predominantly White institutions means they tend to center the experiences of White individuals while marginalizing those of people of color. This has led to an approach that can be more accurately described as “White-washed,” as it fails to adequately reflect the experiences of marginalized groups.
This lack of representation can result in assessments that overlook how individuals of color interpret and respond to certain questions. For example, when Black individuals respond affirmatively to questions like, “When shopping, do you feel that other people are noticing you?” it might not necessarily indicate an increased risk of psychosis. Instead, this response could reflect the reality of heightened scrutiny that many Black individuals experience while shopping. Without accounting for these cultural and contextual factors, there is a risk of over diagnosing paranoia in Black individuals and providing inappropriate treatment.
Paranoia as an Adaptive Response–But Also, a Clinical Reality
The heightened paranoia experienced by Black Americans can often be understood as a rational adaptation to systemic racism rather than solely a clinical disorder. My recent collaboration with former undergraduate student Jake Isenman revealed a positive correlation between self-reported paranoia and experiences of racial discrimination and microaggressions, highlighting the need to view paranoia through the lens of systemic racism (Wolny et al., in preparation).
This vigilance and suspicion can serve as protective mechanisms in a society that devalues and criminalizes Black existence. However, clinicians who lack cultural competence may pathologize these adaptive responses—viewing or treating them as symptoms of a medical disease—thereby leading to misdiagnosis and inappropriate treatment, such as overmedication. Cultural competence, as defined by the American Psychological Association (APA), involves possessing skills and knowledge appropriate for specific cultures and collaborating effectively with individuals from different cultural backgrounds. Without this competence, clinicians may overlook the root causes of distress, failing to address the psychological effects of racism and discrimination and neglecting the broader sociocultural factors at play.
That said, it is also important to recognize that clinical paranoia and schizophrenia are serious mental health conditions that do affect some Black individuals and significantly impair their ability to function. For Black individuals, historical and contemporary trauma can blur the line between delusions and legitimate fears, making it even more complex for clinicians to assess. For example, a Black person who has faced repeated threats of police brutality may develop paranoid delusions rooted in real traumatic experiences, even if the intensity of their paranoia extends beyond present reality. This complicates the distinction between clinical paranoia and justified vigilance, as real-life threats may contribute to the formation of delusions.
Moving Towards Culturally Informed Assessments
Practitioners and researchers must better differentiate between heightened paranoia that serves as an adaptive response to systemic racism and historical trauma, and clinical paranoia meeting diagnostic criteria. Culturally competent assessments should consider an individual’s mental health symptoms and their history of racial trauma.
Tools like the Cultural Formulation Interview (CFI), which consists of structured questions designed to assess cultural factors in mental health, can help clinicians explore cultural identity, explanations of illness, and the influence of social stressors or support systems on paranoia. By using tools like the CFI, clinicians can conduct more comprehensive, culturally informed evaluations and better distinguish between adaptive responses and clinical paranoia.
Mental health professionals must understand how systemic racism influences mental health. Culturally informed approaches provide a framework for understanding paranoia within its broader context, offering support that acknowledges the unique challenges faced by marginalized communities. The significant racial disparities in the diagnostic rates of psychotic disorders—where Black Americans are 3-4 times more likely to receive such a diagnosis compared to their White counterparts—underscore the importance of culturally competent assessments (Schwartz & Blankenship, 2014). While clinician error and lack of cultural sensitivity are contributing factors, broader social determinants of health—such as cumulative trauma, adverse neighborhood conditions, and prenatal complications—also play a crucial role in the development of these mental health conditions (Anglin et al., 2021). Addressing these health disparities requires a comprehensive understanding of how systemic racism shapes mental health outcomes and necessitates adjustments in both diagnostic practices and treatment strategies.
Conclusion
Creating an inclusive mental health system requires more than clinical reform—it demands a collective effort to dismantle systemic barriers. The mental health disparities faced by marginalized groups are not unique to the United States. Across the globe, similar patterns of systemic bias in mental health care perpetuate inequities, underscoring the universal need for culturally informed approaches.
Researchers and clinicians play a critical role in driving this change. By incorporating the lived experiences of marginalized communities into diagnostic tools and treatment plans, they can create a foundation for more equitable care. However, this work cannot rest solely within the realm of mental health professionals.
We all have a role in building a world where heightened paranoia isn’t a rational response to daily life. This includes supporting policies that address racial disparities, challenging discriminatory practices, and reflecting on our own biases. Change doesn’t happen in isolation, and every action—no matter how small—helps create environments where people of color feel safe, valued, and seen.
Together, we can work toward a future where no one’s safety is compromised by structural injustice, and mental health care is truly equitable, inclusive, and reflective of everyone’s lived experiences.
Edited by Jonah Wirt and Joe Vuletich
References:
Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World journal of psychiatry, 4(4), 133–140. https://doi.org/10.5498/wjp.v4.i4.133
Cicero, D., & Ruggero, C. (2021). Commentary– opening a can of worms: The importance of testing the measurement invariance of hierarchical models of psychopathology—A commentary on He and Li (2020). Journal of Child Psychology and Psychiatry, 62(3), 299–302. https://doi.org/10.1111/jcpp.13353
Anglin, D. M., Ereshefsky, S., Klaunig, M. J., Bridgwater, M. A., Niendam, T. A., Ellman, L. M., DeVylder, J., Thayer, G., Bolden, K., Musket, C. W., Grattan, R. E., Lincoln, S. H., Schiffman, J., Lipner, E., Bachman, P., Corcoran, C. M., Mota, N. B., & van der Ven, E. (2021). From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States. The American journal of psychiatry, 178(7), 599–610.
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