Effective therapy with Black women

The murders of Black men such as George Floyd at the hands of the police have put systemic racism against the Black community into the center of the national discourse. But even in this nationwide conversation, the challenges of Black women often go unmentioned—in part because Black women are often pigeonholed as strong caregivers and providers who shoulder others’ burdens and do not share their own.

But burnout and stress are rampant among Black women, especially as many absorb traumatizing news stories and grapple with personal experiences of police brutality and the disproportionate impact of COVID-19 on people of color. There is a pressing need to address this stress, said Angela Neal-Barnett, PhD, a clinical psychologist who is the director of the Program for Research on Anxiety Disorders among African Americans (PRADAA) at Kent State University and author of Soothe Your Nerves: The Black Woman’s Guide to Understanding and Overcoming Anxiety, Panic, and Fear (Touchstone, 2003).

“What we are seeing is that racism on its best days is a stressor, and Black women are often very good, or at least decent, at compartmentalizing that,” Neal-Barnett said. “Over the last 15 or 16 months, racism has been trauma, and that ability to compartmentalize has fallen by the wayside.”

Black women are also simultaneously affected by racism and sexism and may feel under pressure to hide their negative emotions lest they fall prey to the “angry Black woman” stereotype. Psychologists who work with this population say there is much to be done to improve the mental health of Black women, ranging from expanding access to licensed professionals with experience in treating people of color to reducing incidents of racism and microaggressions.

“Racist stressors really stick with you, and they can become racial trauma,” said Candice Hargons, PhD, a counseling psychologist at the University of Kentucky and the founder of the Center for Healing Racial Trauma. “Our research is now showing that those physical health disparities that were thought to be a function of personal behavior are often a function of racism” (Cultural Diversity & Ethnic Minority Psychology, online first publication, 2021).

Mental health and health disparities

While the overall rate of mental health conditions in Black Americans is similar to the rate of mental health conditions in White Americans, Black Americans are 1.5 times more likely than White Americans to report feeling sad most or all the time, and they are 1.6 times more likely to say that things feel like an effort most or all of the time (National Health Interview Survey, 2018). Black women are 1.8 times more likely than Black men to report sadness most or all the time and are 2.4 times more likely than Black men to report feeling hopeless more or all the time.

Black women also face health disparities that translate to a life expectancy at birth that is 3 years shorter than ­non-Hispanic White women (77.9 years versus 81 years), according to the Centers for Disease Control and Prevention (Health, United States, 2017). Infant mortality is 2.3 times higher in Black women than in White women, and maternal mortality in Black women is also more than twice the rate seen in White women (Hoyert, D. L., & Miniño, A. M., National Vital Statistic Report, Vol. 69, No. 2, 2020). “Our research is starting to find correlates of [health disparities] with racial trauma or racist stressors,” Hargons said. “The pathway is through stress and psychological distress.”

Troubling patterns are also emerging among Black girls. Black teenage girls outpace both White and Hispanic teenage girls in suicide attempts, with 15.2% of Black 14- to 18-year-old girls reporting a suicide attempt in the previous 12 months compared with 9.4% of White teenage girls and 11.9% of Hispanic teenage girls (Ivey-Stephenson, A. Z., et al., Morbidity and Mortality Weekly Report, Vol. 69, No.1, 2020). Suicide deaths among Black adolescent girls rose 182% between 2001 and 2017 (Price, J. H., & Khubchandani, J., Journal of Community Health, Vol. 44, No. 4, 2019).

Research led by Jioni Lewis, PhD, a counseling psychologist at the University of Maryland, finds that Black adolescent girls deal with a variety of racist and sexist microaggressions, from sexual objectification to judgment over aesthetics of hair and body type to assumptions about their intelligence (Journal of Counseling Psychology, online first publication, 2021). Black girls are also often subjected to adultification bias, meaning they are seen as less innocent and more adult than same-age White peers. This bias is directed at girls as young as 5 and peaks at ages 10 to 14, with adults perceiving Black girls as significantly less in need of protection and nurturing than White girls, according to a Georgetown Law Center on Poverty and Inequality report (Girlhood Interrupted: The Erasure of Black Girls’ Childhood, 2017). This bias can shape the interactions that Black girls have with systems, particularly the school system, said Jamilia Blake, PhD, a licensed psychologist and professor at Texas A&M University who designed and coauthored that report and a qualitative follow-up (Listening to Black Women and Girls: Lived Experiences of Adultification Bias, 2019). “This increases their risk for greater involvement in the school discipline system, of receipt of more school suspensions, of loss of instructional time, and the school-to-prison pipeline,” Blake said.

Nationwide, 14% of Black girls received out-of-school suspensions in the 2015–2016 school year, compared with only 8% of White girls (U.S. Department of Education Office for Civil Rights, School Climate and Safety 2015-2016, 2018). Black girls represented only 8% of the student population that year, while White girls represented 24%.

“When Black girls are engaging in behaviors that are childlike, it’s not seen as them being kids or age-appropriate, because they’re typically viewed as older,” said Celeste Malone, PhD, the director of the school psychology program at Howard University.

Stereotypes and stigma

There is little research on how adultification bias might impact Black women once they reach adulthood, but as Black girls grow up, they may begin to internalize the level of responsibility that people have placed on them, Blake said. Black women are socialized to be strong and self-sufficient, a stereotype sometimes known as the “Superwoman Schema” or the “Strong Black Woman” role. This role has both advantages and drawbacks, said Inger Burnett-Zeigler, PhD, a clinical psychologist at the Northwestern University Feinberg School of Medicine.

“It helps us to be resilient. It helps us to keep going in the middle of difficult circumstances,” Burnett-Zeigler said. “But the consequence is that strength often means not paying attention to feelings of distress, not paying attention to the impact of familial, relationship, and race-based trauma and how it impacts our thoughts, feelings, and behavior.”

A study of 158 adult Black women by Natalie ­Watson-­Singleton, PhD, a clinical psychologist at Spelman College, found that agreement with the Strong Black Woman schema was associated with psychological distress, which was partially mediated by the women’s perception of lack of emotional social support (Journal of Black Psychology, Vol. 43, No. 8, 2017).

Black women may feel they have to push down negative emotions lest they become overwhelmed, said Neal-Barnett. And to become overwhelmed is simply unthinkable. “To be ‘weak’ and a Black woman is an oxymoron,” she said.

Black women are also judged more harshly than White women when they display anger or frustration. A recent study led by Daphna Motro, PhD, a professor of management and entrepreneurship at Hofstra University, found that observers are more likely to blame a Black woman’s anger in a workplace setting as internal to her rather than due to external factors (Journal of Applied Psychology, online first publication, 2021). As a result, the observers judged Black women as less capable leaders and as worse performers.

Microaggressions can be another drain on Black women’s mental health. In a qualitative study of microaggressions in corporate settings led by Aisha Holder, PhD, a counseling psychologist now at Columbia Health, Black women in high-level management jobs reported being expected to coach or caretake for White colleagues while also having their authority questioned more frequently than other managers at their level (Qualitative Psychology, Vol. 2, No. 2, 2015). They also described the low-level stress of processing microaggressions to rule out possibilities other than racism. “I tend to play the scene over and over again . . . Is it that I’m new here? Is it that they’re all friends? Is this something that was planned in advance?” one participant told Holder and her colleagues.

“It’s this constant consideration,” said Faye Belgrave, PhD, a health psychologist at Virginia Commonwealth University who studies health and well-being interventions for the Black community. “You’re going to think, ‘Am I going to be discriminated against this time?’”

Work coauthored by Lewis finds that as Black women experienced gendered racial microaggressions at higher levels, they increasingly disengaged in order to cope (Psychology of Women Quarterly, Vol. 43, No. 3, 2019). Disengagement coping, however, was associated with an increase in depressive symptoms.

Psychological interventions

To make matters even more difficult, the counseling office is not always a safe place for Black women. In one 2016 study of race, class, and therapist availability by Princeton University sociology doctoral student Heather Kugelmass, MA, therapists were 3 times less likely to offer appointments to working-class help-seekers versus middle-class help-seekers, regardless of race (Journal of Health and Social Behavior, Vol. 57, No. 2, 2016). But within the middle-class group, a pattern emerged in which Black middle-class help-seekers were less likely to be offered an appointment than White middle-class help-seekers. Therapists may also fall into the trap of believing that their Black women clients are strong and resilient and thus coping better than they are, or they may fail to recognize their clients’ strengths because of their own internalized biases.

Psychologists are now working to make the mental health field more welcoming to Black women and more responsive to their needs. Access to therapy remains a pressing issue, and psychologists can play a role in lobbying for expanded coverage of mental health care, said Joy Harden Bradford, PhD, a counseling psychologist based in Atlanta and the founder of the Therapy for Black Girls podcast.

Supporting and mentoring Black therapists and other mental health professionals is another goal. According to data from APA’s Center for Workforce Studies, only 4% of psychologists in the U.S. workforce were Black as of 2015 (See “How Diverse Is the Psychology Workforce,” Monitor, February 2018). According to the U.S. Census Bureau, 13.4% of the U.S. population is Black. This means that Black patients do not just face the typical struggle of finding a licensed professional with openings; they also face an additional struggle of finding a professional who looks like them and has similar lived experiences.

Given the shortage, it is crucial that White therapists and therapists from other non-White populations educate themselves on the specific needs of their Black patients. Black women “are going to be in an interracial experience of therapy a majority of the time,” said Donna Baptiste, PhD, a counseling psychologist at The Family Institute at Northwestern University. “The question is, now, how do we assure them that this person they’re going to work with will understand them?”

Both APA’s Guidelines on Race and Ethnicity in Psychology, approved in 2019, and Guidelines for Psychological Practice With Girls and Women, updated in 2019, cover the intersectional needs of Black women. Key to effective therapy with Black women are therapists who are aware of their own biases and privileges in relation to race and gender and who work to understand how systemic racism and sexism play out in society and in the field of psychology. Other keystones of culturally competent therapy include:

Helping patients manage stress and anxiety. The combination of racism as a stressor and the expectation that Black women are always strong leaves its mark on the body and mind. Sometimes, the role of the psychologist is to help patients realize that symptoms such as headaches or numbness can be tied to psychological distress over racism, Hargons said. Therapists can also teach mindfulness or deep-breathing strategies to help Black women avoid the physiological consequences of stress. Particularly promising are interventions rooted in mindfulness-based stress reduction, loving-kindness meditation, and NTU (pronounced “in-too”) psychotherapy, a spiritually based, Afrocentric approach, according to Cheryl Woods-Giscombé, PhD, RN, a health psychologist at the University of North Carolina at Chapel Hill School of Nursing (Complementary Health Practice Review, Vol. 15, No 3, 2010). Black therapists report using more dynamic and interpersonal interventions and more culturally informed interventions with their Black patients (Scharff, A., et al., Practice Innovations, Vol. 6, No. 2, 2021).

Psychologists can also coach Black women on effective self-advocacy strategies and help them learn to express vulnerability without losing the aspects of the Strong Black Woman schema that serve them. “You don’t throw out the Strong Black Woman image,” said Neal-Barnett. “You throw out parts of it, but you use parts of it to move the women toward healing.”

Fostering openness about racism. Psychologists should make clear that experiences of racism are a safe subject in their offices. Therapists sometimes feel nervous to bring up race, as if they are treading on a taboo topic, said Adia Gooden, PhD, a licensed clinical psychologist. But if therapists are silent on race, their patients might not feel comfortable raising the topic either. “A Black woman might feel like, ‘I cannot talk about all of my experiences of microaggressions or bias in here because there is not room for it,’” Gooden said.

One way to open the topic of racism is to include questions about how patients of all racial backgrounds identify culturally and ethnically in initial intake assessments, Gooden said. “When you ask, you’re communicating: ‘I’m curious about this aspect of you. I think this is relevant to the work we’re going to do here.’”

Understanding that Black women are not a monolith. Another benefit of asking up front about racial and cultural identities and experiences with racism is that the question allows patients to explain what matters most in their lives. “If you’re working with an African American patient whose ancestors were enslaved Black people, that person may have a different experience from someone who is a Nigerian immigrant to the U.S.,” Gooden said. “Asking helps you understand someone’s identities.”

Reaching out, building community

One resource that many Black women must draw on is the strength of their family, friendships, and connections within the Black community. Research shows that Black women cope with racism and sexism by leaning on loved ones and drawing strength from spirituality and the stories of their African American ancestors (Shorter-Gooden, K., Journal of Black Psychology, Vol. 30, No. 3, 2004). “Sister circles,” or groups of mutually supportive Black women, can be particularly healing, said Neal-Barnett, whose work suggests that these groups are beneficial for Black women experiencing anxiety and panic (Clinical Psychology, Vol. 18, No. 3, 2011). “What the sister circles really highlight is that you are not alone,” she said.

Sister circles are also a way to expand mental health access into the community, as they can be embedded into churches, sororities, and other organizations. Neal-Barnett and her colleagues are now expanding the manualized trainings for running sister circles into corporate settings.

Other psychologists are working to reduce the stigma around mental health and to make tools available to Black women. The Loveland Foundation offers financial assistance to Black women and girls seeking mental health care. Black Mental Wellness, an organization founded by four Black female psychologists, hosts a library of free fact sheets, coping strategies, podcasts, and apps that offer information on mental health and resources for handling stress. The organization also hosts trainings and a mentorship program for Black psychology graduate students. Social media has proved a powerful tool for making mental health information accessible, said organization cofounder Dana Cunningham, PhD, a clinical psychologist in Baltimore. The group’s Instagram has more than 138,000 followers. “We have to be willing to give information away,” Cunningham said.

Bradford has also found a way to build community and expand her reach with her Therapy for Black Girls podcast. With ample references to pop culture and what Bradford calls a “ginormous group therapy session” vibe, the podcast unites Black girls and women and helps reduce the stigma of needing help. “It has become very clear to me that much of healing for Black women happens in community, in our relationships with one another,” she said.

Finally, working with Black women means recognizing pain, resilience, strength, and sorrow, said Gooden. It is easy to overemphasize one or the other, she said: “In order to effectively work with Black people, you need to be able to hold space for all of it.”