How Race and Culture Shape Diagnosis: Understanding Misdiagnosis in High-Functioning Adults
How Race and Culture Shape Diagnosis: The Psychology of Being Misunderstood
In therapy, one of the most painful patterns I encounter is this: someone walks into the room, highly articulate, high-achieving, and deeply tired. They have been managing symptoms for years—sometimes decades—without support. They have been misdiagnosed, underdiagnosed, or not diagnosed at all.
When we begin to unpack their experience, it becomes clear that their distress was visible. But it was filtered through cultural assumptions that prevented it from being recognized for what it was.
As a psychologist licensed in New York and California, I work with many clients from racially, ethnically, and culturally diverse backgrounds. A common theme is this feeling of being “missed” by healthcare systems that were not built with their experience in mind.
Diagnostic Frameworks Reflect Cultural Bias
Most diagnostic systems in the United States—including the DSM—were developed using research populations that were disproportionately white, Western, male, and neurotypical. While efforts have been made to expand inclusivity, many foundational assumptions remain.
What this means clinically is that behavior and emotion are often judged against a normative standard that does not account for cultural variation. A Black woman who is vigilant and assertive may be seen as “angry.” An Asian client with somatic symptoms may be told “it’s all in your head.” A Latino man struggling with trauma may be misdiagnosed with a personality disorder. These are not outliers. They are patterns documented across decades of psychological research.
High Functioning Does Not Equal Well-Being
Clients from marginalized backgrounds often learn to perform competence as a survival strategy. They appear composed, successful, and engaged. But under the surface, they may be experiencing chronic anxiety, emotional suppression, relational disconnection, or burnout. The pressure to succeed in the face of bias means many have developed exquisite coping mechanisms—at the cost of feeling seen.
In these cases, distress is often invisible to others, including healthcare providers. It doesn’t look like crisis. It looks like overfunctioning. And when those individuals seek help, they may be told they’re fine, that what they’re describing is normal, or that they’re simply stressed.
Cultural Expressions of Mental Health Are Often Misread
Mental health is not expressed the same way across all cultures. For example:
In some cultures, emotional pain is expressed through the body—headaches, stomach issues, fatigue—rather than through emotional language.
In others, direct emotional disclosure may be viewed as inappropriate or unsafe, particularly outside the family.
Certain spiritual or religious beliefs may shape how symptoms are interpreted, leading to different help-seeking behaviors or explanations.
When clinicians are not trained to recognize these cultural expressions, they may pathologize normal responses or miss important signs of distress altogether.
The Role of Internalized Bias and Silence
Clients who have been overlooked for years often internalize the message that their pain does not count. They begin to doubt themselves. They assume they are too sensitive, not sick enough, or somehow defective for not being able to just “get it together.” This is particularly common among people who have been taught to overachieve in the face of marginalization—who carry pressure to represent their community, prove their worth, or avoid appearing weak.
Therapy becomes the space where those beliefs can be examined and softened. It offers room to ask: What if your symptoms were never trivial? What if they were simply misunderstood?
Toward a More Culturally Responsive Diagnosis
A culturally responsive approach to diagnosis does not rely on checklists alone. It asks deeper questions. It considers context. It recognizes that identity, environment, and lived experience matter. It looks for patterns that may not fit conventional models but are entirely valid.
This approach is not about over-accommodation or political correctness. It is about accuracy. About offering care that truly fits the person in front of you.
In Closing
If you are someone who has spent years feeling misunderstood, dismissed, or missed in your mental health journey—especially if you are from a racially or culturally marginalized background—you are not imagining it. Your story may have been filtered through frameworks that were never designed with you in mind.
I offer therapy for adults across New York and California, with a focus on high-functioning individuals navigating identity, emotional burnout, and the silent impact of being misread. If you are looking for a clinician who will take the time to understand the full context of who you are, I invite you to reach out.
