The other day, I was listening to a popular storytelling and journalism podcast called “This American Life,” which bases its episodes on ‘themes.’ This episode’s theme dealt with people being on television when they didn’t necessarily want to be.

In the episode, a television crew for the show “Cops” is filming a traffic stop. The policeman approaches two silent teenagers and asks to search their car. They agree immediately, though you can’t really hear them. The officer finds what he believes to be crack cocaine in the back seat, and does what they call a NIK test. Later, you hear him casually say, “Yep, that’s crack cocaine.” The show’s narrator mentions that the female passenger is panicked about the result of the test, but you don’t get to hear her panicking. You do know that the teenagers cooperate with the officer’s every command – including the ones that they have the right to refuse – in silence. It’s as if they are afraid of what might happen were they to speak up for themselves. They are placed under arrest, and the scene ends.  I don’t know what you as a reader were thinking about these teenagers’ appearances, but I almost immediately pictured two black teens. 

Implicit bias describes the effect that conditioning has on how we subconsciously judge the world around us. In this example, my implicit bias led me to assume that these frightened criminal suspects were black. In a doctor’s office, implicit bias may lead a doctor to assume that a non-white patient won’t adhere to a medical directive, or that they do not feel as much pain. Implicit bias also has a cousin, called stereotype threat. This is the conditioned fear that one will be mistreated based on negative stereotypes about him or her. In a doctor’s office, a non-white patient may feel the need to demand extra pain medication, fearing that their doctor is subconsciously discounting their pain. Stereotype threat is very uncomfortable, and having to deal with it every day as a black medical student has led me to develop myriad coping mechanisms. 

At the start of my final semester of undergrad, I was stressed from a heavy course load (which included quantum physics, for some reason), had just taken the MCAT and was applying to medical schools, had multiple jobs, and had been eating terribly. I missed the second week of classes with the flu, then missed the next week with back spasms. Soon, I was locking myself in my room, suffering from constant illness, avoiding classes and people, and denigrating my general existence. Knowing that I would literally not survive like this, I took the (courageous, as I now look back on it) step of setting up an appointment with my college’s mental health professionals. 

On the morning of my first session, I filled out a depression and self-harm screening form. It asked questions like How often do you have trouble concentrating on tasks? or How often have you felt that you would be better off dead? I believe the test was scored out of 27 points (27 being the most urgent mental health crisis), and I scored something like a 24. 

After my therapist took a couple minutes to review the screening, we began our session. She was a placid, strawberry-blond woman in her mid-forties, with a doctorate in psychology. She spoke with both a Midwestern twang and repose. Her eyes remained stolid and unblinking behind her thick, black-rimmed rectangular glasses. She explained that she was a cognitive behavioral therapist, which meant that she would tell me to do things like Slow down and ask yourself if you’re truly unworthy of success, or if that is just what your brain is saying in the moment.

I left that first session feeling great. I liked that she gave me actionable advice (keep an anxiety journal; do the things that make you anxious despite your anxiety), liked that she maintained a neutral attitude about everything, never got too personal, never shared about herself, remained distant and detached. This was nothing like the type of therapy that I had seen on television, where therapists were intense, even combative, badgering their patient with logic-smashing cross-questions until the patient was a blubbering, egoless shell of himself, to be built up again as a confident, self-aware success. 

As it turned out, however, my therapist’s lax characteristics were not what I needed in a therapist. Before each biweekly session, I would take the same depression screening, and my scores were just as abysmal as the first time, sometimes worse. Despite my failure to improve over the course of months, our sessions developed an unrelenting monotony. I would tell her that I was having the same problems (inability to leave my room, sheer terror at the thought of seeing people, spaces that I physically could not enter because of some real or imagined trauma living there), and she would give the same advice (just ask yourself…). At the end of each session, she would ask, “Have you been having thoughts of harming yourself or others?” I would answer, “Yes.” Then the session would be done, and I would wonder what exactly she did with that answer, and when exactly this therapy stuff would help me at all. 

I began to suspect that she simply didn’t care, or that she didn’t comprehend the depth of my misery. She remained so detached, even when I felt that I was nearly breaking down in front of her. It sometimes felt like she just wanted to see how far I could fall. I would like to give her the benefit of the doubt, to assume that she was just inexperienced, but the specter of implicit bias always lurked in the back of my mind. It’s part of the curse of being so underrepresented. 

Could it have been that she underestimated my pain? That she saw my black skin and my male body and my stolid demeanor and thought, “He can’t really be that depressed.” These were thoughts that I grappled with. These may seem outlandish to white readers, but black or brown readers who have had white providers know exactly what I mean.  We know that not only have we been harmed by acted-out prejudice, but that we have been conditioned to fear the mere possibility of prejudice. We have known stereotype threat: that hideous need to divide our attention between the task at hand and the fear that somebody (whether consciously or not) is making that task harder for us. 

And this is not just some intangible, psychic burden that we cite when playing the race card. There is a lot of data showing that non-white patients receive worse care than white patients. One study showed that post-surgical pain relief was given to non-white patients at a far lower rate than white patients. This disparity stretched across receipt of epidurals during labor, analgesic cancer treatment, primary care, the emergency room, and much more. Another meta-analysis concluded that blacks receive less pain relief than whites and other races across all pain types, especially those in which a source of pain is not immediately apparent, such as fibromyalgia or Crohn’s disease (I would argue that psychic pain such as depression or anxiety could fall into this category, too). We also know that both discrimination and perceived discrimination damage mental health. 

Therein lay the problem with my time in therapy. I started therapy to heal, and I’m sure that my therapist was doing her best, and that she had the best intentions for me. However, I couldn’t help but wonder whether she was truly understanding me, or if she even cared to. That is part of the damage done by implicit bias and stereotype threat: You are constantly searching in the shadows for prejudice, wasting your gift of vision. 

Implicit bias research is still in its early stages. There has, however, been tremendous progress: Almost everybody with a college education now knows what implicit bias is, whereas as twenty years ago, there wasn’t even an epistemological framework for the concept. The next step for research in implicit bias – once even the most obstinate pundits are convinced – is to implement methods to limit its damage, particularly in healthcare. Currently, the most common advice from researchers is to “check your bias.” If, for example, you assume that a female patient coming into your office is exaggerating her pain, pause and ask yourself whether this assumption is based on a stereotype or if there is real evidence to support your assumption. Other suggestions include seeing patients as individuals, putting yourself in their shoes, and diversifying your network of friends. Many organizations have also developed implicit bias training programs.

Implicit bias is now a widely accepted phenomenon with a growing body of research supporting its damaging nature. As with any health equity issue, we need to raise awareness before we can make lasting changes.