Beyond Representation: Rethinking Emotional Asymmetry in Psychiatric Diversity Models

SPECIAL REPORT: DIVERSITY

The psychiatric field has increasingly embraced diversity, equity, and inclusion (DEI) frameworks. From institutional pledges to workforce diversification to the inclusion of cultural factors in diagnostic manuals, progress has been made. But beneath this visible transformation lies an unspoken asymmetry: an imbalance in how emotional expression and affective labor are distributed, recognized, and pathologized across lines of race, power, and structural privilege. As DEI becomes increasingly procedural, it risks reinforcing rather than challenging the emotional hierarchies that define psychiatric engagement.

Emotional asymmetry refers to the unequal expectation and social tolerance of emotional expression based on positionality. In psychiatric settings, this means that structurally marginalized individuals are often expected to modulate or suppress legitimate affective responses. They are pressured to perform composure in the face of distress, or risk being labeled as “difficult,” “noncompliant,” or “borderline.” Meanwhile, individuals from structurally privileged groups are more readily granted emotional latitude. These asymmetries are not merely interpersonal dynamics; they are entrenched in diagnostic criteria, institutional culture, and broader societal narratives about who is allowed to be hurt and who must remain composed.

For instance, consider a Black patient who presents with symptoms of hypervigilance, mistrust, and emotional detachment following workplace discrimination. Without a structural lens, these symptoms may be pathologized as signs of a personality disorder or treatment resistance. But when viewed through the framework of racialized trauma and institutional betrayal,^1,2 they emerge as adaptive responses to chronic stressors. The risk of psychiatric misrecognition, in which structural injuries are interpreted as individual pathology, is amplified when clinicians lack training in the emotional dimensions of structural racism.

This pattern is particularly pronounced in therapeutic encounters where clinicians unconsciously expect racialized patients to minimize distress, avoid critique, and demonstrate gratitude for care. These expectations often go unspoken, yet they shape the transference and countertransference dynamics in subtle but profound ways. As Fanon observed, the psychological violence of racialization creates a double consciousness where marginalized individuals must constantly navigate both their internal experience and external expectations of emotional propriety.³ The asymmetry is also mirrored in institutional spaces where emotional restraint is demanded from staff of color, even in response to microaggressions or policy failures, while White colleagues may be granted more emotional expressiveness, including frustration or disengagement, without consequence.⁴

These dynamics are not simply cultural misunderstandings. They are structurally patterned outcomes of what Black feminist scholars have long identified as affective labor: the unpaid and often unrecognized work of managing one’s emotions and those of others in hierarchical contexts.^5,6 Hartman’s analysis of slavery’s afterlife illuminates how contemporary emotional regulation among Black individuals often represents a continuation of survival strategies developed under conditions of racialized violence.⁷ In psychiatry, this labor often takes the form of self-censorship, hyper-composure, or what could be described as “strategic calm” among racialized patients and professionals alike. The emotional asymmetry becomes both a survival strategy and a barrier to care.

Psychiatric diversity models, as currently practiced, often remain silent on these dynamics. They focus on increasing representation or delivering culturally competent care without interrogating the affective substrates of racism or institutional betrayal. But without a framework for affective accountability, or an understanding of how power shapes emotional expectations and interpretations, even well-meaning interventions can reproduce harm. What is needed is a shift from optics-based DEI to structurally informed emotional realism.

The following 3 clinical commitments are essential:

• Treat emotional responses to injustice as data, not deviance. When a patient is angry, withdrawn, or distrustful, consider the structural conditions under which that affect has formed. What histories of betrayal, silencing, or misrecognition might be shaping this response?
• Interrogate the emotional norms of psychiatric settings. Whose emotions are expected to be managed, and whose are tolerated or even valorized? What types of emotional expression are welcomed, and which are punished or pathologized?
• Build diagnostic humility. Recognize that DSM categories often reflect dominant cultural scripts about normative emotion. Be open to reinterpreting symptoms in light of systemic stressors and lived experience.

The task before us is not to abandon clinical judgment but to deepen it. To ask not only what someone feels but why their feelings are seen the way they are, and what structural dynamics shape that perception. In doing so, we begin to develop a psychiatry that does not simply include diverse patients but that listens to them on their own terms.

Case Vignette 

“Maya,” a 27-year-old Afro-Caribbean woman who was recently diagnosed with major depressive disorder, is referred for therapy after an unsuccessful trial of selective serotonin reuptake inhibitors. In sessions, she appears emotionally flat, rarely makes eye contact, and is reluctant to discuss family history. Her therapist, a White clinician trained in cognitive behavior therapy, interprets her disengagement as “guardedness” and raises concerns about a possible comorbid personality disorder. But when a peer support worker of similar background joins a session, Maya shares a detailed account of racist bullying in her workplace and her fear that speaking candidly would result in retaliation or misinterpretation. The peer worker contextualizes this as a common form of emotional suppression among Black professionals in predominantly White institutions, describing it as a strategy of “strategic silence” used for safety rather than deception. The treatment plan shifts to incorporate narrative therapy and structural validation, with improved engagement.

Discussion

This vignette underscores the stakes of emotional misrecognition. Without a structurally informed lens, Maya’s protective behaviors were mistaken for pathology. With affective insight, they became part of the clinical narrative. Judith Herman’s framework for understanding trauma responses helps illuminate how protective behaviors, including emotional numbing, hypervigilance, and avoidance, are adaptive responses to systemic harm rather than intrinsic pathology.⁸

Psychiatry cannot afford to keep mistaking its own blind spots for diagnostic clarity. When it ignores the affective residues of history, how racial science, institutional betrayal, and emotional silencing have shaped psychiatric norms, it mistakes emotional protection for pathology. We must ask not only who is feeling but whose feelings are systemically misread, minimized, or erased. Emotional asymmetry is not a flaw in patient behavior; it is psychiatry’s mirror. It reflects the field’s unfinished reckoning with power, perspective, and pain.

What would it mean for psychiatry to treat emotional asymmetry not as a flaw in patient behavior but as a mirror held up to its own practices? It would mean recognizing that emotional expressions cannot be universally standardized without reproducing harm. That the language of “insight” or “appropriateness” is shaped by culture and power. That psychiatry’s tools, however evidence-based, still operate within a historical framework that has often misread emotion as deviance. As Audre Lorde reminded us, the master’s tools will never dismantle the master’s house.⁹ Psychiatric frameworks that pathologize justified anger while demanding emotional performance cannot simultaneously heal the wounds they create.

This does not mean abandoning diagnostic rigor. It means supplementing it with a critical awareness of how emotional meaning is constructed. It means valuing cultural formulation interviews not as sidebars but as central to clinical epistemology. And it means building interpretive frameworks that allow for complexity and that do not demand emotional performance as the price of care.

Concluding Thoughts

Psychiatry must move beyond the optics of inclusion and into the depths of emotional justice. Emotional asymmetry is not an abstraction; it is a daily reality for patients and clinicians navigating systems not built for their truths. Let us build a field that meets them there.

Dr Fields is an associate research scientist in the Department of Psychiatry at Yale School of Medicine.

References

1. Comas-Díaz L, Hall GN, Neville HA. Racial trauma: theory, research, and healing: introduction to the special issue. Am Psychol. 2019;74(1):1-5.

2. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. 2nd ed. Zed Books; 2012.

3. Fanon F. Black Skin, White Masks. Markmann CL, trans. Grove Press; 1967:232.

4. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271-286.

5. Hill Collins P. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. Routledge; 2009.

6. Hochschild AR. The Managed Heart: Commercialization of Human Feeling. University of California Press; 2012.

7. Hartman SV. Scenes of Subjection: Terror, Slavery, and Self-Making in Nineteenth-Century America. Oxford University Press; 1997.

8. Herman JL. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. Basic Books; 1997.

9. Lorde A. Sister Outsider: Essays and Speeches. Crossing Press; 1984.