Race, whether we choose to believe it or not, plays a significant role in our individual identities and the way we move through the world. It shapes our experiences and how we’re treated. To leave it out of the discussion as it pertains to mental health, when it can be one of the most significant factors, is a tremendous loss. One felt primarily by Black people, who are often the most overlooked and under treated.

Let’s start with the numbers. Despite common misconceptions, rates of mental illnesses for Blacks are similar with those of the general population. But the outcomes are not the same. Black people often receive inadequate quality of care, and overall lack access to practitioners who are culturally competent.

The Shortage Of Black Therapists

Several factors play into this problem. The first is healthcare providers themselves. We’re experiencing a massive shortage of psychiatrists and psychologists in general and the scarcity is even deeper for Black clinicians. Merritt Hawkins, a company that provides healthcare insights, released a white paper in 2018 showing that there are currently about nine psychiatrists for every 100,000 people. They say that is almost half the ideal number of 15 per 100,000 which is optimal for mental health.

Now, when we dive deeper into the numbers, we find that in 2015, only 4 percent of psychologists in the U.S. workforce were African American. Of the rest, 86 percent were white, 5 percent were Asian, and 1 percent were multiracial. Clearly, this is much less diverse than the overall population where Blacks make up just over 13 percent according to the US Census Bureau.

In other words, there simply aren’t enough Black mental health practitioners to go around. Not only does this shortage make it difficult to find a Black therapist, but it also means Black therapists may have heavy caseloads.

Why Black Therapists Matter

The result is that a lot of Black people will be in the care of non-Black practitioners. At first glance, this might not seem like such a big deal. After all, these are trained medical professionals, why would it matter?

Here’s one of the issues: Without cultural and historic fluency, many won’t understand the full scope of what it is their clients may be going through. The result is misunderstanding and potentially misdiagnosis.

The other obstacle is trust. It’s well documented that patients who feel aligned with their practitioner do better than those who are not aligned. This doesn’t necessarily mean they need to be the same race, but the practitioner has to be able to demonstrate an authentic understanding and be able to build trust with their patient. The reality is Black clients may not feel as open with non-Black clinicians. Or, if they do open up, they could become frustrated by having to explain more nuanced feelings tied to race.

“I think at a foundational level, you want to have a therapist that can empathize with you culturally. And the reason I pay for therapy is to work through my issues. Rather than spend time explaining the Black lens through which I live,” says James Murray, founder of TheraMatch, a platform that provides an easy way to match with Black and LatinX therapists on Instagram.

“That’s not to say that non-black therapists can’t learn to empathize, but a black therapist already has that understanding built into who they are. And I think that’s important,” Murray adds.

We spoke to a number of Black people who are in therapy currently, one resounding reason they’d prefer a therapist who looks like them had to do with the re-education aspect.

Timothy Thomas whose current therapist is a white woman shares that he chooses not to bring up race in their sessions. “It’s a conversation that is hard to have with someone who’s not of color. There are certain aspects in which you almost have to coach or educate before you can really get into the heart of the conversation. And that’s just not something I’m willing to dedicate my time to,” says Thomas.

“So, oftentimes, I don’t have that conversation with them or have it very superficially because it’s really not something I’m willing to sacrifice X amount of the 45 minutes session—talking through the issue before I really dig into it.”

Thomas has seen a number of therapists over the years, and although he’s content with his current practitioner, mentioned that he’d jump at the opportunity to see a Black male therapist, which he refers to as a unicorn.

The solution to this lack of diversity in the healthcare profession, in general, is recruiting and retaining more people of color. And, much of the work starts with the education system.

A group of psychiatrists wrote in Academic Psychiatry that they see a need for intervention as early as middle school. They wrote in their editorial piece, “Middle and high school students, who may be vulnerable to discrimination, limited exposure to career options, and other socioeconomic adversities that may derail future education, need to be encouraged to pursue careers in health care.” Some examples of these kinds of programs are the Health Professions Recruitment and Exposure Program (HPREP) at institutions like University of Texas Southwestern, Yale, and University of Chicago. These pipelines allow students to get early exposure to careers in medicine and mentorship.

“College students will also benefit from mentoring and exposure to health care work opportunities. We would encourage academic psychiatrists to look not only at their undergraduate colleges affiliated with their institutions but also at other colleges surrounding their institutions. Bright, interested students of color may be close by and in need of mentoring and support. We encourage academic psychiatrists to look beyond the expected internal candidates,” they go on to write. While their focus is in academic psychiatry, the same measures would be needed for clinical psychiatry.

The Problem Of Misdiagnosis

Unlike things like a broken wrist or high cholesterol, you can’t detect mental illness with a simple X-ray or blood test. The subjective nature of making a diagnosis can be particularly problematic when you account for racial differences.

One issue that you will often hear therapists talk about is misdiagnosis. A Black child who is disruptive in school may be identified by the teacher as having operational defiant disorder and be treated punitively. On the other hand, a white child being equally disruptive may be identified as having ADHD and be handled with more compassion and less punishment. This isn’t to say overt racism is at play, but subtle societal cues create a different narrative for these children.

Psychiatrists and psychologists make similar judgements when they’re diagnosing. Take for example a recent study done at Rutgers University which explored whether African-Americans are more likely to be misdiagnosed with schizophrenia. The researchers hypothesized that clinicians overemphasize the relevance of psychotic symptoms and overlook symptoms of major depression among African-Americans versus other groups.

To investigate, they looked at 599 Blacks and 1,058 non-Latino white and found that clinicians failed to effectively weigh mood symptoms among African-Americans. This suggests that racial bias (even if it’s subconscious) could be a factor in the diagnosis of schizophrenia in this population. As the researchers guessed from the onset, it seemed that the clinicians were putting more emphasis on psychotic than depressive symptoms in African-Americans, and it was this weighting that skewed diagnoses toward schizophrenia, even when these patients show similar depressive and manic symptoms as white patients.

The consequences are pretty bad since you wouldn’t treat schizophrenia the same way you would treat a mood disorder like depression. The misdiagnosis could make the actual problem worse and even increase the risk of suicide.

Another study shows that regardless of the diagnosis, race may play a factor in how dangerous clinicians view patients. This distinction can then impact treatment.

Equal Treatment

Clinicians play a role in providing the right care, but the patient does too. Experts point to four main patient factors that impact treatment:

  1. Stereotypes. This category includes stigma and fear of judgement.
  2. Hesitancy. Cost is a big factor here, but also the sense that help isn’t urgently needed.
  3. Relatability. When the patients don’t bond with the therapist, they can inadvertently sabotage the treatment plan.
  4. Lack of knowledge. Patients are not always aware of how the process works, in part because it is stigmatized and not discussed in their circles.

For many years, there was a deeply rooted stigma surrounding mental illness within the Black community, and in some instances there still is. For most Black families, the subject of seeing a psychologist was taboo or a sign of weakness. Instead, they were prompted to “pray it away” or ignore their underlying issues altogether.

Along with this is a sense or skepticism and even paranoia among some Black communities. There is an inherent distrust of healthcare practitioners within the Black community, as a result of implicit bias as well as historic instances of medical malpractice.

For clinicians, the issues that plague diagnosis also plague treatment. Studies have shown that most health care providers appear to have inherent prejudice in terms of positive attitudes toward whites and negative attitudes toward people of color. This often leads to Black people experiencing less than favorable bedside manner, empathy, or treatment from their medical providers. This sometimes trickles over into the mental health space as well, which influences most Black people to seek the help of those who look like them.

Where Treatment Takes Place

Compared with whites, Blacks are more likely to use emergency rooms or primary care, rather than see a mental health specialist. Due in large part to the lack of knowledge regarding the types of treatment available. Or overall denial of the fact that their issues may stem from a deeper psychological ailment.

Regardless of race, treating psychiatric issues via the emergency room isn’t ideal. (Though, it is needed, especially in cases of suicide ideation). The main problem is it’s too late in the stage—you’ve already reached an emergency level of need. But beyond that, an emergency room is chaotic, crowded, and may not have the exact specialization. Still, according to the Center For Disease Control data, many psychiatric cases come through the ER every year. In fact, 6 percent of all the emergency department patients—of all ages—had a psychiatric condition. More than 20 percent of these psychiatric patients were admitted to the hospital, compared with just over 13 percent of the medical patients.

Microaggressions And Code Switching Threaten Wellness

Along with the relatability of having a Black therapist, the burden of working in predominately white spaces where microaggressions are rampant plays and integral role in how some seek treatment.

“I’m the only black girl on my team [at work], and I’m honestly surrounded by white women all day. I don’t need that gaze and everything that comes with that in a space that’s supposed to be a safe environment for me, I would feel like I’d have to put my guard up. I’d feel like I have to perform or be on edge and ready to defend myself. And I didn’t want that for therapy,” says L’Oreal Thompson Payton who is currently seeing a Black woman psychologist.

“[Having a Black therapist] definitely contributes to the happiness and the overall experience because I can just be myself. I can let my guard down, literally let my hair down and don’t have to worry about all the questions that we get asked,” adds Thompson Payton.

For many Black people in corporate settings, code-switching is the norm in order to not solely fit in, but survive on a daily basis, and can cause a great deal of mental conflict.

Code-switching is the act of switching between two or more languages or varieties of language in a conversation. This constant juggle between presenting yourself in one way that is considered more palatable by your co-workers and employer compared to who you are authentically presents its own set of traumas.

“We don’t all have the same experience, but we have similar experiences. [Working with a Black therapist] I just didn’t feel like I had to overexplain or dive into things. And [she would say] ‘you’re editing yourself, you don’t have to do that’” says Janell Hickman. “Versus with someone who’s not of my race, especially if I had a white therapist, I would have tried to present things in a different manner to almost proposition myself in a more positive light.”

Though other minority groups do have some shared experiences, the sentiment regarding preference of therapist remains, given the specificity of each culture.

“I had a Hispanic counselor that was really good, but I just felt with everything going on with COVID and what was happening in the U.S. I really needed someone that could relate to me in a different way. And I think that it’s important. People of color can definitely relate, but I think Black woman to Black woman, is a different experience,” says Hickman.

Not All Black Experiences Are Created Equal, Either

The discussion surrounding race and therapy becomes even more layered when you factor in sexual orientation, socio-economic background, and identity. For some, like CJ Trahan II, finding someone who has a full understanding of his journey as a Black gay man has been trying.

“You just want to feel comfortable with speaking about your experience to someone who might have gone through something similar. And because of that, I have been trying to find a therapist who is specifically Black, gay and preferably male, which has been a journey of failures,” says Trahan. “It’s hard to find someone who checks all those boxes, has the background to be able to handle childhood trauma, LGBTQ experiences, Black experiences, and that is affordable”

Trahan has yet to find a Black LGBTQ+ therapist who accepts his insurance or offers sliding scale payment options.

  Upbringing and socio-economic background also play a role in the need for a therapist of the same race.

“[My therapist and I] came from very similar socio-economic backgrounds—middle to low income. [He understood] what it’s like coming from Brownsville, Brooklyn, and then going to work for a Goldman Sachs and that imposter syndrome—there was no explaining that,” says Junior Louis.

Louis notes that having a Black male therapist who could understand his journey of advancing from one lifestyle to the next and navigating primarily white spaces helped him feel more at ease during their sessions. Given his therapist’s first-hand experience of a similar life situation, Louis felt he was better equipped to help him unpack certain aspects of his behavior and mental health.

The issue of identity also manifests itself in a unique way for those who are multiracial. For a number of multiracial people, finding that right fit proves to be even more difficult.

“In a perfect world, would I have a therapist who has a multiracial background? Yes. I think that would be beneficial because the way society views me is nonwhite. Did I grow up in mostly white spaces? Yeah. Do I feel like I’m part of white spaces? No,” says Amanda Moses.

 Today’s Advancements and The Journey Ahead

Though the mental health industry has a long way to go before we begin to see a significant shift, a number of strides have been made in an effort to ensure more Blacks and people of color are receiving treatment from those within their communities.

Therapy For Black Girls is a pioneer online space committed to encouraging the mental wellness of black women and girls and features a directory of therapists nationwide.

TherapyForBlackMen.org is a newer directory of therapists that specifically highlights Black male therapists, who, according to a number of interviewees, is one of the more difficult demographics to find.

Other organizations, such as TheraMatch help take the guess-work out of figuring out whether or not your therapist is a good fit by pivoting the old model of finding a therapist to video. TheraMatch utilizes Instagram video to help give those seeking Black and LatinX providers a more interactive introduction.

“[Our users] are saying things like, ‘I really appreciated the way she explained the therapist/client relationship,’ ‘Or, I really loved her energy.’ And those are nuances and details that you don’t get out of just looking at [a practitioner’s] profile,” says Murray.

As we look ahead on the mental health landscape, accessibility is a major factor, but increased research and a broader understanding across racial backgrounds is at the core of the issue. Though there are more racial-ethnic minority groups entering the field, examination and studies of mental health ailments and treatment lack diversity.

“As someone who’s getting ready to go to school to work in the [mental health] field as a black woman, there is some emotional preparation that I’m having to do,” says Moses, who is headed to school in the fall for clinical social work.

“A lot of the mental health field is coming from a white perspective, and a lot of studies have been done just on white people, just on white males.”

Last Updated: Aug 10, 2020