A Black Psychologist Shares Some Tips On Starting Therapy

Scientists can say with confidence that racism is bad for Black mental health. Multiple experts using different approaches to studying racism-related problems have determined that racial discrimination is psychologically and physically harmful to Black people. This may seem obvious, but even those of us who are well versed in the research likely fail to fully grasp the depth of these findings.

A professional “collaboration” can help. There are psychology professionals who are trained to guide you through your scariest, most debilitating fears so you don’t have to be numb, profusely sweating, dizzy, or paralyzed at the idea of talking to a room full of people, flying on an airplane, driving down the street where you experienced a traumatic accident, or even meeting Ms. Oprah Winfrey. A therapist can guide you toward your own resources so getting out of bed isn’t so hard and purpose can move dread out of your mind. If you are overwhelmed and need help working through some considerable setbacks in your life — the loss of a loved one, a miscarriage, your addiction to painkillers and sleeping pills, your crippling feelings of inferiority, and your recurrent thoughts of driving off the road on your way home after work (and that was just in the last month) — therapy can help resolve the trauma. It can empower you to rise from hopelessness to make beneficial changes in how you live.

Unfortunately, the mental health system can be daunting. Emotional health care is not necessarily designed with Black people in mind. The discipline of psychology is made better with racial and ethnic diversity, but sincere efforts to address the psychology of a people who have been systematically subjected to inhumane treatment are relatively nonexistent. (After all, psychology is the field of study that provided “evidence” that Black people are inferior to white people.) There have been some efforts to be more inclusive of but there is much more work to be done. You can, nevertheless, benefit from learning tools and strategies that help with common problems that everyone faces. I aim to help you navigate a complex mental health care system to get what you need for yourself and those you care about.

Know When It’s Time for Professional Help

• Don't wait for crisis mode. In crisis mode, the goal is to get to a place of feeling stable so you are in control of your life and of your feelings. Once you are out of crisis, you may not be motivated to be in therapy. Instead, you return to the rat race that is your life — the one that drove you to crisis in the first place. Ideally, you seek therapy before crisis so you can learn skills to manage your life rather than continually hoping that things will work out.

• Everyone can benefit from a boost in psychological fortitude — including you. Maybe you have made excuses for not seeking therapy of any sort because you are so good at just continuing on. But your efforts to persevere despite one or two forms of distress can, over time, become compounded with an ever-growing list of challenges.
• There is no expiration date on working through unresolved grief and trauma.

Common Misconceptions About Therapy

• A common concern in the community is that once you tell someone “your business,” it will get out. Anyone who is a licensed practitioner has an ethical responsibility to maintain the confidentiality of a client. Even if your therapist happens upon you in public, they would ideally not acknowledge you, especially if you are with other people. The only time that your therapist can disclose to another professional that you are in therapy is with your written consent. In most states, if you are believed to be a danger to yourself or others or to a child or if therapy is court-ordered, then the therapist is mandated to acknowledge that you are in therapy. Even in those cases, however, limited information is provided.
• Another common misconception is that you have to be crazy or on the verge of an emotional breakdown to be in therapy. This is not true. You do not have to have a serious problem with depression, anxiety and fear, or alcohol addiction to get help. Given that African Americans are most likely to seek help once problems have become debilitating, you may be at this juncture. Unfortunately, problems are harder to address once they have become serious. I cannot stress this enough. If you say that you want to shut down the engine to rest and reassess, but are unable to do so, you may benefit from therapy now before the engine gives out on its own.
• Finally, therapy is not about being “locked up.” Historically, therapy was associated with “insane asylums” where very troubled individuals spent their lives. Indeed, Black people are disproportionately “put away” both in prisons and in long-term mental health facilities. I would be wrong if I did not acknowledge this very real concern. That we represent less than 15% of the United States population but closer to 25% of those in long-term care suggests that we are overrepresented in mental health facilities. In many ways, these outcomes are a function of (1) misdiagnosis and undertreatment, (2) lack of resources, and (3) delayed efforts to get help. Timing is important so you receive an accurate diagnosis. This is another reason to seek help before you are in a crisis state.

Locating the Right Therapeutic Help

Ideally, you would get a personal recommendation for a therapist from someone who has gone to that person, but I understand that you may (1) still have reservations about disclosing that you are looking for a therapist and (2) have wondered whether your personal business might get “leaked” to that person through the therapist. Until our community, including African Americans, Africans, and West Indians, see therapy as beneficial and not as a sign of weakness, you may choose to seek help more discreetly. Here are some resources.

Through your job

• Employee assistance programs (EAP) are voluntary programs offered through an employer that provide employees free and confidential assessments, short-term counseling, referrals, and follow-up services for their personal and work-related problems. Most programs provide counselors who are equipped to address issues affecting mental and emotional well-being like the ones that we have been discussing.
• Your health insurance provider may have mental health coverage, and if you do, the health insurance company will likely provide a list of mental health providers. This information is often accessible online.

Online searches

You'll want to look or ask specifically for “psychotherapists.” The search for “counselor” typically works but is also quite broad. Your pastor is also a counselor but will not likely have training in psychotherapy. A psychotherapist provides therapy for the mind and behavior. There are numerous online resources that detail the various types of mental health professionals. Here are some:

• Therapy for Black Girls: Therapists provide contact information along with a photograph and brief description of their expertise. The site is not comprehensive by far, but many Black and African American therapists from across the United States have signed on to the directory.
• Psychology Today: This directory of therapists offers photos and detailed credentialing. The site provides a stamp for therapists in their directory whose name, license, and contact information have been verified.
• The American Psychological Association's psychologist locator: Only members of the American Psychological Association (who are presumably licensed psychologists) can be listed in the directory. Similar to the other sites, profiles include photos, and areas of expertise are detailed and identifiable using region or therapist name.
  
• Research universities: Many have psychological clinics on campus that provide care to people in the community through doctoral students. Clients benefit from cutting-edge care on a sliding-fee scale.
• The National Alliance on Mental Illness (NAMI): NAMI has been around since the 1970s as a national grassroots organization. It is a tremendous resource that provides education about mental health–related topics and advocacy for bringing attention to psychological problems. There are about 650 state and local affiliate organizations across the U.S. who work in your community to raise awareness and provide support and education resources.

Consider group support

Even if you are the only Black person in the room, you may still benefit from sharing with others who can relate to your struggles. Suffering in isolation is much more difficult than suffering with others. Until circumstances shift, you may be the only one seeking support who looks like you. When my dad passed away, I participated in a monthly grief support group for a year. I was the only one there who had lost a parent. I was twenty-nine years old. The facilitator and all the other members of the group were white women in their sixties or older who had lost their spouse. Having someone listen to my stories about my dad was helpful. Sometimes, you just want someone to listen to you— someone who can relate somewhat to your experience and tell you that you are going to be okay.

What All Those Credentials Mean

Your needs and preferences will determine who is the most qualified professional for you. Most available practitioners have master’s level degrees. There are also providers who specialize in treatment of substance-use problems who may not have graduate degrees but have earned a certification to practice.

• Licensed professional counselors (LPC), licensed mental health counselors (LMHC), and marriage and family therapists (MFT) have completed master’s degree level coursework in psychology, counseling, or marriage and family therapy and obtained the required number of supervised clinical hours before being authorized to see clients independently.
• Licensed clinical social workers (LCSW) are also credentialed at the master’s degree level and provide individual, family, and group therapy.
• Psychiatric nurse practitioners provide mental health services and are often affiliated with a medical center or hospital.
• Licensed psychologists have typically earned doctoral-level PhDs or PsyDs.
• Psychiatrists are doctors of medicine (MDs) who prescribe medication. Psychiatrists are specifically trained in the use of medicine to improve mental health. The medications that influence brain functioning are known as “psychotropics.” Some psychiatrists also provide talk therapy, but the majority do not. In most states, psychologists cannot prescribe medications.

In some ways, finding a therapist can be a dice roll, but review their personal websites for their expertise and what they offer to clients. It may also take some of the pressure off of your search if you know that the provider that you begin with may not be the provider that you end up with. Make a list of three possible therapist options from the start.

What to Expect in Therapy

In the very first session of structured therapy, your new therapist begins by discussing confidentiality and limits to confidentiality, expectations about cancellations, and other logistics. The therapist will obtain background information from you (e.g., work, level of education, living situation, etc.). She will ask what it is that brings you in for therapy. She will also talk about her approach to therapy. The amount of information that the therapist shares about herself will vary but will be relatively limited in the interest of focusing more on you. If you prefer to ask questions of the therapist to feel more comfortable, you can do so. These are some of the questions you may have:

• What is your approach to psychotherapy? In the first session, the therapist needs to describe her understanding of how problems come about and how best to solve them through therapy. Therapists are trained in various approaches, and we understand the source of the problem based on our training. As an example, some might assume that current problems are based on unresolved issues from your upbringing versus others who focus on how you see the world today. As a result, we propose different solutions based on how we understand the problem. My own approach to therapy is cognitively oriented, and the therapy or interventions that I supervise fall in the realm of “cognitive behavioral” work that addresses problems that arise due to how people think about the world around them.
• How does the therapist know where to begin? Your new therapist will often ask you questions until she understands what is troubling you and your expectations for what life will look like when you have completed therapy. Your expectations are tied to your goals. Most clients go to therapy wanting life to be different or better but do not often have a specific goal in mind. Your therapist can help you zero in on a goal if she has a sense of the problem, but ideally, this is a collaborative effort. Just because you say that you are tired and frustrated does not mean that your fatigue is the same as the last client’s fatigue. It may take a couple of sessions to break down what all is really going on.
• How long will this take? This will vary…a lot. It is unlikely that any actual “change” would take place in the first session. However, the therapist may ask you questions that will cause you to seriously evaluate your life situation and give you a different perspective and new insight. Over the course of therapy, you and your therapist will work together to address the unhappiness that brought you to therapy. You’ll do so in a way that makes sense to you. At agreed-upon intervals, you can evaluate how things are going. To be most effective, you will want to be as open as you can possibly be so the therapist understands the true nature of your problems. You will also want to complete any assignments, tasks, or homework that the therapist advises.

You May Have to See a White Therapist

Because therapy relationships are so important, you may feel that you can only trust and be comfortable with a Black therapist. This feeling is absolutely understandable. You would not want to subject yourself to yet another “space” where you have to pretend to not be you, avoid your African American vernacular to speak standard English or even worse, have your therapist act like she doesn’t see you as Black. Finding a Black therapist might be ideal. But ethnicity is not the only criteria, or the most important, for you to consider. Your Black therapist might be nice, but if she has no experience with trauma, your capacity to improve will be limited. The therapy might feel good because she is a great listener in a way that no one else in your life listens, but you won’t address the trouble that your trauma has been causing you.

There are white therapists who are perfectly fine seeing a Black client. This is important because when you are struggling emotionally, the last thing that you want to do is see a therapist who is uncomfortable around Black people. However, I assure you that there are therapists out there who would be good at establishing a relationship with you. You are best served if you do your homework, get reliable referrals, and research your options.

As you might expect, most therapists are white women. The mental health system is, in many ways, a microcosm of our larger society. Not everyone is “culturally competent” and able to demonstrate their ability to work with individuals who are culturally different from them. To my knowledge, graduate programs in clinical psychology do not admit doctoral students based on their capacity to not be racist. The assumption is that they are admitted with some common sense not to be racist in our field of psychology and that they will learn to demonstrate cultural competence while in graduate training.

Most accredited programs, at least in psychology, embrace cultural competence as an objective. That means that students in training take a course or two in multicultural psychology and are expected to be able to successfully navigate the nuances of working with clients who are Black, Asian, Latinx/Hispanic, LGBTQ, or from a lower income bracket—any reality that impacts how the client experiences the world that is not a mainstream, middle class, Eurocentric lens. For some, a course or two with practice seeing clients from diverse backgrounds is sufficient.

If you find that a white therapist may be your only option, you can assess whether or not that person could be a good fit for you.

• Ask what percentage of her clients have been African American or Jamaican or who are first-generation United States citizens. If the question elicits discomfort, that might be all the data that you need to move on to the next therapist on your list.
• She might make missteps. Mainstream psychology treats cultural competence as a place where we arrive as professionals. We either check the competence box or we do not. It is better, however, for a therapist to recognize that he or she is continually evolving and must be open to that process. Given the success that you have had in navigating predominantly white work settings, you have a sense of whether or not a white person has some “humility” about their whiteness. It does not mean that they will not make any missteps. However, they certainly won’t make any egregious mistakes, like trying to touch your hair in the first session or insisting that the microaggression that you experienced was in your head.
• You want to know that your therapist will be genuinely receptive when you give her feedback about her interactions with you. Therapists who aspire to cultural humility are willing to be critical of themselves. They are flexible and willing to learn more about you and, importantly, what your culture means to you. They also obtain information without relying solely on you as a sole source of knowledge.

What If You Need Medication?

Prescription medication can help you get out of a rut so you can benefit from therapy. A chemical imbalance is difficult to overcome on your own. If you have been in therapy for months or years with tremendous difficulty achieving small goals despite having a well-trained therapist, there is a chance that you could benefit from medication. Here's what you should know.

• If you do need medication, it is best prescribed and managed by a psychiatrist. They can work with you to figure out if an antidepressant, anti-anxiety, or other psychotropic prescription could be helpful for you. Your primary care physician can also prescribe medication. (In fact, primary care doctors prescribe a significant proportion of anti-anxiety and antidepressant medication in part because people are more likely to see their doctor and not follow up with a psychiatrist.) However, determining prescription medication can be a delicate process.
• There are a number of different types of medication. A psychiatrist would be best equipped to consider alternative psychotropic medications and at the appropriate dosage. Also, if you are on other medications, the psychiatrist can problem solve if your medications are impacting one another. Perhaps the lorazepam that your psychiatrist prescribed would be better for you at a lower dosage. On the other hand, it may work right away at the initial prescription. You may begin to notice new energy and a renewed sense of focus that you never knew could exist for you. You might wonder why you did not consider antidepressant medication sooner.
• You might have uncomfortable side effects. If you tell your doctor that you have been so stressed that you have difficulties sleeping at night and find yourself being overly worried about your work performance during the day, she may prescribe something that ends up making you feel strange and jittery as a side effect. There are various medications that could have different side effects. The doctor will do their best to find the right type for you.
  
• If you are tempted to stop taking your prescription after one week, let the professional who prescribed the medication know about any uncomfortable side effects. Call the office, and speak to the nurse. Do not keep your experience to yourself and simply discontinue your medication. Take time to figure out what works for you.
• Commit to challenging your biases so you can make the best decision for your health and well-being. Often, I find that people who say that they oppose medication and therapy will take Tylenol PM several nights per week to fall asleep. For some reason, they don’t have any concerns with over-the-counter meds. If this sounds like you, it could be a sign that you want a quick fix instead of real change. When it comes to your very complex psychological fortitude, the perfect formula may take some time to figure out.

Change Cannot Be Amazon-Primed

Therapy is not magical. It does not work overnight. If you go into a session thinking that you will be healed of your ills inside of two weeks, you will be disappointed. When you decide to see a professional, you may be at the height of distress or at your lowest psychological fortitude. The therapist’s first responsibility is to establish a relationship with you and gain some insight about what is going on for you, how the problem came to be, and what you have done to manage it.

The therapist may have to uncover decades of hurt in order to understand your current problem. What this looks like is that you address one problem, but then another seems to emerge unexpectedly. You would not expect someone to fix your car without diagnosing what the car is doing that it’s not supposed to do, how the problem came about, and whether or not you did anything to address the problem.

However, if there is a chance that you would not return to that therapist because you do not think she can help you, it is best that you let the therapist know up front. In doing so, the therapist can take time to determine what might be done to fix your most pressing problem (because there is often more than one) or let you know what additional information is needed to address that problem. In any case, follow your instincts. If you do not feel comfortable with the therapist, you can let her know that it is not working out. If you are comfortable, but feeling antsy, you may want to settle in for a while. For therapy in general, plan on no less than twelve to sixteen sessions, but this depends on your level of distress and your willingness to work on assigned tasks outside of session.

You can get professional help—whether you are addressing a serious disorder or you are hoping to increase your psychological fortitude. If you feel isolated and just need to be heard because no one is listening to you, it may be helpful to talk to someone who can provide you with support. You will likely have to go out of your comfort zone to find the help that you need, but therapy will help you with a new and different perspective and give you some tools for coping. When you find the right professional to help you make your way to wellness, all the effort is well worth it. ●

Reprinted and adapted from The Unapologetic Guide to Black Mental Health: Navigate an Unequal System, Learn Tools for Emotional Wellness, and Get the Help You Deserve with permission: New Harbinger Publications, Inc. Copyright © 2020 Rheeda Walker, PhD. Get your copy.

Rheeda Walker, PhD, is a tenured professor of psychology in the department of psychology at the University of Houston. She is a behavioral science researcher and licensed psychologist who has published more than fifty scientific papers on African American adult mental health, suicide risk, and resilience. Walker is recognized as a fellow in the American Psychological Association due to her scholarly accomplishments.

Walker has been a guest expert psychologist on T.D. Jakes’s national television talk show, and her work has appeared or been cited in The Washington Post, CNN Health, the Houston Chronicle, and Ebony magazine. Her expertise has been critical to mentoring doctoral students in cross-cultural psychology since 2003. Walker was previously a lead consultant in the statewide African American Faith-Based Education and Awareness initiative in Texas. She conducts workshops, and coordinates with churches and other organizations to address emotional wellness.