Black mental health matters

By Lindsey Phillips

July 27, 2020

Racial violence and discrimination are woven into the fabric of the United States. The way policies and laws are implemented. The weaponization of Whiteness and privilege. Disparities in education and health care. The horrible and senseless killings of Black people throughout our nation’s history and into the present day.

How do daily acts of racial violence, injustice and discrimination affect the mental health of Black Americans? What is it like to work and live beside people who don’t value you as a human being? What is it like to live in a country where your rights are frequently threatened?

Dominique Hammonds, an assistant professor and testing coordinator in the Department of Human Development and Psychological Counseling at Appalachian State University, provides a quick glimpse into the complexities of being a Black woman and counselor in a racist society. Hammonds, wearing a shirt that read “Black and Educated,” was shopping in Walmart recently when a White woman passed by her and casually said, “You’re disgusting.” In that moment, Hammonds felt powerless. She feared the consequences of saying or doing anything in response.

Hammonds left the store and shortly thereafter went into a counseling session where her client recounted feeling powerless, angry and upset because of injustices they were experiencing in their life. Hammonds had to compartmentalize her own feelings of powerlessness to help the client.

Counselors play an important role in helping Black Americans cope with and heal from racial stress and trauma, but they can do more. Namely, they can also take steps toward changing an unjust and racist system that powerfully and negatively affects the mental health of Black Americans.

A distrust of mental health

Research indicates that Black Americans are 20% more likely to report serious psychological distress than are White Americans, yet they are less likely to use mental health services.

Loni Crumb and Janeé Avent Harris, who are both assistant professors of counselor education at East Carolina University (ECU), examined, along with two of their colleagues, the negative perceptions of mental illness and treatment among Black Americans. They found that stigma, a lack of trust in mental health care and a mislabeling of Black people’s presenting concerns make this group more apprehensive to seek counseling. Financial constraints and a lack of access to culturally responsive mental health care are additional barriers, explains Crumb, a research and innovation associate with the Rural Education Institute in the College of Education at ECU. (See their article “African Americans’ perceptions of mental illness and preferences for treatment” in the Journal of Counselor Practice for a more detailed discussion of their findings.)

This distrust is not unfounded. Black Americans have been misdiagnosed and overdiagnosed with schizophrenia for decades, for example. (For more, read “The historical roots of racial disparities in the mental health system” by Tahmi Perzichilli at CT Online.)

Angie D. Cartwright, an associate professor of counseling at the University of North Texas (UNT), stresses the importance of looking at how and why the mistrust of mental health began in the Black community. “Institutional and systemic racism is the foundation of a lot of our medical treatments, including mental health counseling,” Cartwright says. “And, historically, when [Black people] invite others into [their] homes and communities, then problems happen.”

Sitting with discomfort

Counselors, not clients, should be the first to broach issues of racism. This isn’t necessarily easy or comfortable.

Counselors often conflate comfort and safety, but they are two different things, insists Cartwright, a licensed professional counselor and licensed sex offender treatment provider who is the clinical director and owner of North Texas Counseling and Wellness.

As she explains, being comfortable enough to broach the topic does not mean the topic itself will be comfortable. “It’s not comfortable to say, ‘I was discriminated against,’ ‘I had a gun pulled on me’ or ‘I was fired because my boss is racist,’” she continues. “There are some conversations we will always feel some discomfort talking about. And that’s OK.” But clients should feel safe enough to share their experiences — ones that will often be uncomfortable for counselors to hear, she adds.

“You have to get comfortable with being uncomfortable,” says Hammonds, a licensed clinical mental health counselor (LCMHC) in North Carolina. “Part of the [counseling] skill set is learning how to have these discussions in a way that feels comfortable.” For example, can counselors say the word Black, acknowledge their own ethnic identities or discuss racism knowledgeably? If not, then clients know they won’t be able to go beyond a surface-level discussion with them, Hammonds explains.

What counselors say doesn’t even have to be overly complicated, notes Hammonds, an American Counseling Association member. They can simply say, “I just want to check in. There’s a lot going on around us right now. What’s that been like for you?” or “I’m curious how you as a Black American might be affected by racial violence and oppression.”

Being open and brave about this topic will likely result in some missteps. That’s part of the process, says Hammonds, who encourages counselors to use those mistakes as opportunities to learn.

One misstep may be getting defensive when clients express anger, distrust or sadness about their experiences. “If you find yourself getting defensive — trying to explain away the client’s experiences or identifying with client experiences and feeling like you have to apologize … on behalf of the system — don’t,” Hammonds says. “All you’re doing [in getting defensive] is communicating to the client that you’re still not comfortable and haven’t done your own personal work around this.” And apologizing just puts clients in a position where they feel obligated to say, “Oh, it’s OK,” she adds.

Instead, she advises counselors to reflect on their own internal experience and to tune in to what might be prompting that response. Perhaps it’s a case of the counselor wanting to protect their own ego, or maybe they are masking their own discomfort or lack of knowledge. If counselors find themselves becoming defensive in session, they can tell the client, “I feel like I’m reacting to something right now, and I recognize that I need to do some self-reflection. But I don’t want to heap that on you.” But do this briefly, Hammonds says, or else the session becomes about the counselor rather than the client.

Building trust and rapport also becomes critical to creating a sense of safety for these clients. Too often, counselors jump to diagnosis and treatment because the mental health system encourages them to have a solid plan and work toward a goal fairly early in treatment, Hammonds points out. She encourages counselors to slow down and first invest time in establishing good relationships with their Black clients.

Context matters

As Avent Harris, an ACA member, points out, counselors won’t be aware of needing to broach the topic of racism unless they understand its historical and political context. Put simply, they have to know what to look for and ask about.

“You don’t learn this context or gain this cultural awareness by just reading the DSM [Diagnostic and Statistical Manual of Mental Disorders],” says Avent Harris, who specializes in multicultural considerations in counselor education and the role of spirituality in Black mental health help-seeking behaviors. She advises counselors to move beyond reading only counseling texts to explore the works of Black scholars, theologians and authors.

Counselors may also need to adjust a technique or approach to better fit with their clients’ experiences. For example, the thought of going for a run in the evening sounds straightforward, but for many Black people, and Black men in particular, it can evoke a sense of fear. They question whether they will be safe or if their choice to run could cost them their life.

If a client brings this fear up in session, it could be dangerous for the counselor to use a thought-stopping technique, with the aim of interrupting, removing and replacing the client’s “problematic thoughts,” Hammonds explains. Suggesting that the client simply stop thinking that running could harm them ignores their experiences and the existence of the racism embedded in society, she says.

Instead, Hammonds, president-elect of the North Carolina Counseling Association, says the counselor should consider the context around the client’s fear of running alone at night. Where does that fear come from? How does society contribute to or perpetuate this client’s fear and anxiety?

“Those are the types of discussions that we need to be making space for,” she says.

Self-awareness and honesty about biases

Hammonds stresses the importance of counselors reflecting — honestly — on their own experiences and biases. As she points out, counselors often like to think, “I took this multicultural course, or I’ve worked with clients from diverse backgrounds, so I’m doing OK.” But it may not mean that at all, she emphasizes.

This self-awareness starts with counselor training. Working with diverse clients is the best way to learn to appreciate differences and to examine one’s own biases and beliefs, says Crumb, an LCMHC in North Carolina.

This diversity should also extend to counselors’ consultation groups. Avent Harris, an LCMHC associate in North Carolina, looks for colleagues who will provide honest feedback and challenge her own thoughts and beliefs. She says that if she has an uncomfortable moment in session, these colleagues would ask, “So, what made you uncomfortable in that moment? What questions do you need to ask yourself to reflect on that moment?” They wouldn’t just echo her thoughts or tell her “not to worry about it,” Avent Harris says.

Hammonds recommends that counselors continue to record and watch themselves in session just as they did during graduate school and supervision. “There’s so much value in replaying your words and listening from that outsider’s perspective,” she says. The process affords counselors a chance to (re)consider their words, think about the purpose of their statements or actions, and evaluate whether they really listened to and heard their clients.

Counselors should also get their own counselor. “Some of this stuff is deep-rooted. It takes time to dig up those roots, to understand them, to untangle them and to repot them,” Cartwright says.

She jokes that her mother always told her, “Never trust a beautician with bad hair.” This same principle applies to counselors, she says. They have to make sure they take care of their own mental health before working with clients on their well-being. “And clients will be able to tell if you … have done your work,” she adds.

Cartwright, the project director for UNT Classic (a program that addresses disparities in mental health services for Black and Hispanic populations in the Dallas-Fort Worth metro areas) and UNT ICBH Project (a program that supports graduate students during clinical training), suggests that her colleagues, especially those who hold identities associated with privilege, work with a counselor who identifies with a marginalized group or with intersections with which the privileged colleague struggles.

They should also intentionally put themselves in a position in which they are the minority, continues Cartwright, a member of the ACA Advocacy Task Force and president of the International Association of Addictions and Offender Counselors, a division of ACA. For example, she suggests that White counselors attend a Black church one Sunday. “If you are uncomfortable for that short time that you’re there, imagine what your Black clients feel like on a daily basis when they are constantly in spaces dominated by White people,” she observes.   

Finding voice and value

Black clients report to counseling with the same common presenting concerns that other clients have. But in addition, Hammonds says, they often seek counseling because of issues of “voice and value.” They have experiences that either minimize their voice or communicate — overtly or covertly — that their ideas, opinions and problems don’t matter or don’t matter as much as those of others, she explains. Feeling undervalued, dismissed and unheard can lead to anxiety, depression and other mental health issues, she adds.

Cartwright specializes in underserved populations in counseling and counselor education, mentorship in counselor education, and offender and addictions counseling issues. She once worked with a client who was experiencing racism and discrimination at her job. The former client was the only Black woman on a large corporate team, and she noticed that meeting times would suddenly change without anyone alerting her. She also got the sense that her co-workers were talking about her behind her back. At first, she internalized this discrimination and started thinking that she must be bad at her job. She felt like an impostor.

But after another colleague confirmed the woman’s suspicions of racial discrimination, the former client filed a lawsuit and won. The win came at a cost, however. She learned that co-workers had purposely changed meeting times without letting her know. Other colleagues whom she had thought were well-intentioned had made racist and hurtful remarks about her that were uncovered during the lawsuit and investigation.

As a result, the client began to question her judgment and worth. Cartwright helped the client learn to feel valued and trust herself again. They worked on challenging the client’s thoughts that she wasn’t good enough. For instance, they used self-affirming techniques such as daily affirmations and “I” statements that allowed the client to identify and acknowledge her strength and resilience.

Even if counselors can’t relate to being discriminated against at work, they probably can identify with feeling like their voice hasn’t been heard, Hammonds says. With that perspective, counselors can take intentional steps to empower these clients in session.

For example, Black clients often feel like they can’t or shouldn’t tell counselors if they didn’t like the way the counselor phrased something or if a moment in session made them uncomfortable, Hammonds notes. But they should be made to feel comfortable voicing those thoughts, she continues, and it’s up to counselors to create a space that invites that feedback.

Hidden struggles

A May 31 article in the Washington Post reporting on protests in the wake of the killing of George Floyd described a less visible impact of racial violence: “the private weariness and anguish felt by many [B]lack people in the country.” In other words, many Black people are exhausted.

Emotional exhaustion is another reason that Black individuals often seek counseling, Hammonds says. Besides being fatigued from the discrimination and injustices that they experience daily, they often find it necessary to code-switch — changing the way they talk and express themselves when they are outside of their homes and Black communities.

To help explain this concept, Hammonds uses the analogy of counseling professionals switching their “hats” or roles. They may go from teaching to supervision to having a counseling session with a client and back to teaching again, all in the same day, which can be taxing.

“Switching roles, having to constantly pause and reconsider how much you can share and what is your role in this new context, and always being aware of what you can and can’t say and what you can and can’t do is exhausting,” Hammonds says. “And that’s an emotional labor that many White Americans aren’t required to do.”

Black women often face an extra burden. As Avent Harris explains, “Black women are expected both inside and outside their community to not be vulnerable, to not share emotions and to carry the weight of everything on their shoulders.”

This unrealistic expectation can take a toll on mental health. In fact, many of Cartwright’s clients struggle with the “Black superwoman syndrome” — the myth that Black women are impermeable. They feel pressure to do it all and to do it well. Although this isn’t really a syndrome, it does help explain the chronic stress these women endure while trying to juggle multiple roles and keep up with the daily demands placed on them by family, work and community.

Cartwright’s clients often discuss feeling misunderstood at work and how co-workers minimize their experiences. Cartwright normalizes these experiences for her clients, but she also expresses how sad it is that this is their “normal.”

The trauma of racial violence

Instances of brutality and violence against Black people are not new, and neither are the racial disparities that regularly confront them. The main difference today is the ability to easily document such instances, says Hammonds, whose research interests include technology in counseling, multicultural counseling and community determinants of mental health. Almost everyone today has a smartphone in their pockets, and more people are using them to record acts of race-based violence and to demand justice and accountability.

These videos also continually expose others to these traumatic and heinous acts. This can be particularly traumatizing for Black people, who often internalize the traumas they witness because they know it could have easily happened to them, Hammonds says.

The disparaging comments on social media can also be traumatizing and triggering for Black Americans, Crumb adds. For instance, they may read a racist comment made by a supervisor or colleague. Then they have to return to work and sit beside that person, knowing how that person really feels about them.

“And so often, [Black people] are expected to move through the world, to hear all this, to see all this, and have no emotional reaction or response,” Avent Harris says. Counselors can help change this by validating clients’ emotional reactions to racial violence and discriminatory remarks, she adds. This involves letting them know that it’s OK to feel disappointed, sad, angry, scared, anxious or whatever else they are feeling.

The trauma of being exposed to racial violence and remarks also has a collective effect. “Collective trauma is exposure to stressful events that threatened a sense of safety on a group level,” Hammonds explains.

On a recent episode of The Thoughtful Counselor podcast, Hammonds described how repeated exposure to racial violence and discrimination operates like a wound that won’t heal: “That spot’s been nicked so many times. We can go about the process of healing, but before you know it, there is another nick. Then you’re walking around doing your best to cope, shielding that spot, anticipating situations that might nick you again. … You are always on edge. You’re withdrawing. Your trust is slow to build in other people and situations. You feel angry and sad. And you start to think, ‘Is there something wrong with me? Why can’t I get out of this cycle?’”

This collective trauma correlates with symptoms of depression and posttraumatic stress disorder such as avoidance, reexperiencing, numbing and hyperarousal, she adds.

If a community experiences stress together, then counseling approaches that draw on the power of relationships are helpful, Hammonds says. These approaches include relational therapies, psychodrama, drama therapies, creative approaches and group therapy.

Hammonds often incorporates music into her sessions with clients. She describes music as being akin to a picture book because it connects people to a certain memory, place, emotion or experience in their life.

When clients can’t easily describe their thoughts, feelings or perceptions in their own words, she asks them to think of a song that best captures their emotions or that represents what they see around them. She then pulls up the song and plays it in session, asking the client, “What is powerful about this song? How do the lyrics or beat affect you?”

Impacts on Black children

In the summer of 2016, Philando Castile was fatally shot in his car by a Minnesota police officer during a traffic stop. Castile wasn’t alone. His girlfriend, Diamond Reynolds, and her 4-year-old daughter witnessed the entire incident.

After the shooting, Reynolds, who was now in handcuffs, was understandably distraught and emotional. Her daughter tried to comfort her, exclaiming, “Mom, please stop saying cusses and screaming ’cause I don’t want you to get shooted.” A few minutes later, the girl said, “I wish this town was safer. … I don’t want it to be like this anymore.”

The girl’s words illustrate how racism and racial violence affect children even at a young age. “Black youth are just as affected as their Black parents are by systemic racism and injustices,” says Crumb, an ACA member whose research interests include rural and school-based mental health services. Black children are affected directly and indirectly. They witness racial violence and discrimination themselves, and they hear adults talking about it at the kitchen table. “Then, they assume these thoughts, these fears … [and] this distrust,” Crumb adds.

Again, counselors should take the initiative to broach the topic of racism with these youth. Crumbs calls it “taking the temperature of the room” because counselors can check in to see how children are doing. For example, a counselor could say, “This has been a tough summer with COVID-19 and a lot of people getting harmed and dying. How are you feeling?”

Then counselors should let the children guide the conversations, Crumb says. Some may verbalize their feelings. Others may use play or draw a picture to express their emotions.

Crumb points out that school settings are often the only access that some Black communities have to counselors. But because of mistrust and fear, they may not view counselors and schools as “safe spaces.” Crumb advises counselors to be mindful of current and historical racial inequities within school systems and to alter their approaches accordingly in attempting to connect with these children.

Younger children may not have the vocabulary to easily communicate their feelings. They often “speak” through play and toys. So, Cartwright recommends that counselors keep an assortment of toys, dolls and activities that will allow children to communicate in the way in which they feel most comfortable. If they want to use a brown doll, counselors should make sure it is available to them, she adds.

But as Reynold’s 4-year-old daughter demonstrated, some Black children possess an early awareness of racism and a vocabulary to discuss it. They often have little choice. Black children will be exposed to inequities earlier than their White peers because of their parents’ lived experiences and the conversations they overhear, Avent Harris explains.

Crumb encourages counselors, especially school-based counselors, to be courageous in advocating for Black youth. Black youth are often overlooked academically and are disproportionately suspended, she says. Counselors can be vocal in questioning why that is the reality. Likewise, if diagnoses of attention deficit/hyperactivity disorder and conduct disorders are disproportionate toward one ethnicity, counselors can ask questions and press for answers.

More than that, counselors can do something about such disparities. For example, they can lead professional development trainings for teachers, Crumb says.

Partnering with the Black community

Black people may rely on informal networks of support such as family, friends and their church communities when it comes to issues having to do with their mental health, Crumb says. She add that counselors should encourage clients to continue using these supportive networks because it is imperative that they have trusted individuals to whom they can turn to discuss their experiences of race-based trauma.

Counselors should also reach out and form relationships with stakeholders in Black communities. Crumb and Avent Harris recommend partnering with community organizers, historically Black Greek-letter organizations, those involved with the juvenile justice system, law enforcement personnel and faith leaders.

Faith leaders are often both spiritual and political leaders in the Black community, Avent Harris says, so collaboration with them is crucial. “A lot of times, how [Black Americans] conceptualize events, crises, pain and suffering is coming from [their] spiritual beliefs systems,” she adds.

In an article written for CT Online after the 2015 church shooting in Charleston, South Carolina, that took the lives of nine Black people, Avent Harris suggested that counselors could meet with Black pastors and offer to speak in their Sunday morning services, co-sponsor a mental health day or provide referral resources.

Counselors should also think of these partnerships as a preventive measure. Counselors need to be invested and involved with Black communities before crises happen, Avent Harris stresses. She challenges her colleagues to name five contacts they have a working relationship with in the Black community and could reach out to immediately. If they can’t name five, she says, then they have some work to do.

Less talk, more action

The words diversity and inclusion have steadily gained prominence in the counseling profession, but Avent Harris believes this has allowed counselors to largely become complacent and not move past thinking of “change” as simply including and hiring diverse individuals.

“It’s not just diversity and inclusion. It’s how we’re doing equity work, how we are doing anti-racism work,” she emphasizes. “What are our actions behind the words that we say? And do our actions align with what we say and who we say we are as a profession?”

Avent Harris, like many other Black people, is exhausted from having the same conversation over and over again about what the Black experience is like. “It’s time to move beyond that talk and really implement action,” she says.

Taking action doesn’t mean that all counselors have to hit the streets and protest, but they can commit to influencing the spaces they are in, Crumb says. Maybe that’s writing an article. Maybe that’s offering a training. Maybe it’s working to inform policy. Maybe it involves working toward making positive change in their communities or within themselves.

Cartwright also suggests one small step counselors could take that would have a huge impact: making their services more accessible to communities of color by offering one pro bono slot a week or having a sliding scale.

Although 2020 hasn’t been the year we wanted, it may be the one we need. Every day, we hear the global rallying cry, “Black Lives Matter.” Behind that cry are Black people who are suffering and dying because of systemic racism. We hear the refrain: Trayvon Martin, Tamir Rice, Eric Garner, Philando Castile, Charleena Lyles, Atatiana Jefferson, Breonna Taylor, Ahmaud Arbery, George Floyd, Tony McDade, Rayshard Brooks, and countless others who have died.

These are the tragic killings that make the news. But how many others die daily without drawing widespread attention? How many more face daily injustices or discrimination?

Yes, their lives matter. And their mental health does too.