CLEVELAND, Ohio — When licensed professional counselor Tamara Ferebee meets with her Black female clients, they talk Black girl to Black girl.
There’s no need to explain why a Black person might feel anxious while driving, or how microaggressions in the workplace cause low self-esteem. They know what it’s like to open your social media and see a child who could be yours crying because police used pepper spray on her.
While some clients feel comfortable talking to a therapist of any gender or ethnicity, others prefer to confide in someone who looks like them. For people of color, it means that client and therapist are on the same wavelength because of shared cultural references.
This story is part of the ongoing cleveland.com series “Coping Through COVID,” which aims to help Northeast Ohio residents manage the stress of COVID-19 by examining the mental-health and behavioral-health aspects of the pandemic. The series tells individuals’ stories and explores various challenges and strategies with experts.
The COVID-19 pandemic has hit the Black community disproportionately hard, not only in terms of severe cases of the illness, but also in mental health.
Having a therapist from the same community is more than just preference — it’s the most effective way to deliver needed help and avoid misdiagnoses.
Black adults (48%) and Hispanic or Latino adults (46%) are more likely to report symptoms of anxiety and/or depression than white adults (41%), according to a study released this month by the Kaiser Family Foundation.
“You don’t want to talk to someone who doesn’t understand your culture,” said Ferebee, associate executive director of human services administration, for the National Association of Black Counselors. The professional organization, based in Chester, Virginia, works to raise the number of black counselors in the United States.
Therapists who are people of color are more likely to understand race-based traumatic stress, or racial trauma. They are also more likely to recognize that Black people often describe mental health symptoms differently than the general population, and that misunderstanding cultural cues can lead to misdiagnosis.
“There are always race-related overtones that make mental health problems a little larger and a lot heavier. We have to recognize that,” said Nia Jones, a licensed master social worker with the Black Mental Health Alliance.
The Baltimore-based organization provides culturally relevant mental health education forums, training and referral services for Black and vulnerable communities.
For minority individuals who want a counselor of their race or ethnicity, the search is complicated by the low number of Black mental health professionals.
Less than 10% of the total number of mental health counselors in 2020 were African American, according to the U.S. Bureau of Labor Statistics.
“We need there to be more (therapists of color) to increase access,” said Marsheena Murray, a child psychologist at MetroHealth Systems.
Why cultural competency matters
When therapists and clients share a common culture, they spend less time trying to understand each other and more time getting to the nitty-gritty of interpersonal problems.
For instance, Ferebee’s Black patients commonly say, “I feel some kind of way about that.” It means, “I feel upset or sad about something that happened in my family or friend group.”
A white therapist might ask, “How did you feel?”
“We don’t have to do that,” Ferebee said, referring to Black behavioral health professionals. “I know, in the course of the conversation, it will come out how they feel.”
When Ferebee prescribes exercise to Black women as a way to manage moods, she knows that many Black women don’t like to sweat. She’ll suggest walking in an air-conditioned mall, or using a stationary bike with fans mounted on it.
Often her clients confide that they didn’t discuss childhood sexual abuse with their white therapists because they didn’t want the therapist to form negative opinions about Black families, Ferebee said.
Jones understands destructive stereotypes in movies and television about Black women, such as the hypersexualized jezebel, the ever-helpful mammy or the angry black woman. These stereotypes have roots in slavery and are connected to racism and discrimination.
“You don’t spend time explaining it,” Jones said. “You spend time healing from it.”
Culturally sensitive therapists of all ethnicities need to recognize the signs of race-based traumatic stress, or racial trauma. This refers to an emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes.
When they hear news accounts of Black people being shot by police or harassed while bird watching or walking in their neighborhoods, they feel as if the incident could have happened to them or a loved one, Jones said. The resulting racial trauma can express itself as depression, anger, recurring thoughts of the event, low self-esteem, headaches, chest pains, insomnia and hypervigilance.
More therapists of all races are being taught cultural sensitivity as part of their training, and that wasn’t always true in the past, Murray said. “It’s a larger focus now,” she said.
When misunderstanding leads to misdiagnosis
It’s important for health care professionals to be trained to recognize depression and other mental health issues in Black men and women, even though the symptoms might sound different than expected.
Black people may be more likely to describe physical symptoms related to behavioral health problems, such as when Black women talk about aching all over or feeling tired when describing depression.
Many Black children are misdiagnosed with ADHD or bipolar disorder when actually they are suffering from untreated trauma, intermittent explosive disorder or PTSD, all disorders that can arise from growing up in a violent area, Ferebee said.
Intermittent explosive disorder is a lesser-known mental disorder marked by episodes of unwarranted anger or rage.
Black men who talk about symptoms related to mood disorders or PTSD are more likely to be misdiagnosed as schizophrenic, according to a 2018 article published in Psychiatry Online.
Health care professionals who are biased, whether consciously or unconsciously, or lack cultural competency can result in misdiagnosis and inadequate treatment for people of color, according to the National Alliance on Mental Illness.
“Mental health (providers) need to be culturally competent enough to look at the source of the behavior to interpret why the child is emotionally reactive — usually from trauma,” Ferebee said.
Why there are so few therapists of color
Diversity has long been a problem in the mental health field.
A 2013 study found that only about 6% of psychologists, 13% of social workers and 21% of psychiatrists are minorities.
Attitudes in the Black community against seeking mental health treatment and using antidepressants also discourage young people of color from pursuing careers in behavioral medicine, mental health experts said.
If more Black people talked about having a therapist and the benefits of therapy, it would raise awareness of the profession in the Black community, Jones said.
The highest hurdle is the lengthy and expensive training required to become a licensed therapist.
In order to become a licensed independent social worker in Ohio, students must first earn a master’s or doctorate of social work degree, have 3,000 hours of professional supervised practice in social work, pass a criminal background check, and pay more than $300 for the application fee and licensing exam.
The costs of prep courses for the licensing exam, and the exam itself, add to the burden.
In Northeast Ohio, “it’s not necessarily easy” to find a therapist of color, especially when patients also need a provider who takes their insurance, is accepting new patients and specializes in their problem area, MetroHealth’s Murray said.
Finding a therapist from a minority community is easier during the pandemic due to telehealth appointments, which can connect patients and therapists across regions, Murray said.
Hospitals and other providers offer names and photographs of counselors on their websites, making it easy to conduct an initial search, Murray said.
Professional organizations such as the Black Mental Health Alliance and the National Association of Black Counselors offer scholarships and training with the goal of encouraging more young people of color to enter the field. It’s important to let people know that there are Black mental health professionals in their communities, Jones said.
If these efforts to diversify the profession bear fruit, it will be easier for patients to connect with a therapist who understands them.
How to find a minority therapist
Here are organizations that offer directories of therapists who are people of color or culturally competent, as well as information and educational materials:
Searchable database of culturally competent behavioral health therapists.
Directory of black and Latino mental health therapists.
Nonprofit that works to erase the stigma surrounding mental illness in the Black community.
Online toolkit that provides Omega Psi Phi Fraternity chapters with the materials needed to educate fellow fraternity brothers and community members on depression and stress in Black men.
Directories for LGBTQ, Latin, Black, Asian and Indigenous patients seeking therapists.
The professional organization offers a searchable database of minority therapists.
Searchable directory of African-American therapists
Mental wellness information and resources for Black women.
Nonprofit that supports the emotional well-being of young people of color.
Listing of mental health professionals across the country, podcast and an online support community.