Now that systemic injustice and inequity are back at the forefront of our discussions, Black mental health and wellness is everywhere. Think pieces, opinion pieces, interviews, panels, and more are trying to answer questions of how to increase access to services. While the focus tends to be centered around money and stigma, the discussion has missed the mark when it comes to how to attract and train more Black and affirming providers for Black clients. Statistics suggest that only 1 to 4% of providers are Black. While these discussions do mention the interplay of stigma and the education and specialties Black professionals choose, I haven’t seen many that dig into the reasons why so few Black people choose to be and stay mental health providers.
History of Racism in Mental Health
It is no secret that mental health professions have a long history of being tools of White Supremacy and oppression. This must be the start of the discussion because this is something that many programs never teach. When we fail to educate on the ills of a field, we end up with providers who unwittingly learn to continue the legacy of oppression. When Black people enter the field, they either follow the same path of ignorance or, in their independent studies, they find gaping holes in the education for social work, counseling, clinical psychology, and psychiatry.
The two biggest examples of the weaponization of the mental health field are Drapetomania and Schizophrenia. Drapetomania, aka Runaway Slave Syndrome, was an “illness” coined by American Samuel A Cartwright to explain why enslaved people tried to escape the harsh and frequently lethal conditions they were subjected to (Cartwright, 1851). Drapetomania was treated by preventative whippings and/or amputating their toes. In the 1960’s and 1970’s, Black people were involuntarily hospitalized and overwhelmingly diagnosed with Schizophrenia for expressing civil rights ideals (Metzl, 2010). While institutionalized, they were heavily medicated, restrained, or worse. These are only two of the most infamous ways that psychiatry and mental health have not only overlooked Black experiences, but also actively aimed to further harm Black people.
The Difficult Journey Becoming a Black Mental Health Provider
The unfortunate fact is that White Supremacy still rules the mental health field, making it difficult for Black providers to get into the field. To become a licensed provider in the United States, at minimum you need a Masters degree. While Black Women have been deemed the most educated population, Black people are also more likely to have student debt. Why does this matter? Because Masters and Doctoral degrees (yes, even PhD’s) are costly and frequently require unpaid internships and, compared to the cost of the degrees, pay in the ,helping fields is low. It is worth noting that financial aid at the Masters and Doctoral level mainly consists of loans. This makes unpaid internships even more of a barrier to completing your degree program. It is a gross assumption of privilege as well as a capitalist gatekeeping measure to force people to pay tens of thousands of dollars for school to work 20 to 30 unpaid hours a week for 2 or more years. In the classrooms, many Black students are faced with the overwhelming Whiteness of their program’s teachings. Black theorists and providers are not in the main curriculum outside of maybe HBCU’s. Black professional organizations are not brought into the school for activity and job fairs, and questioning these issues is frequently met with frustration and hostility from the academy.
Once out of school, those at the Masters level must complete about 2 years of supervised work to be legally allowed to practice independently and supervise. These jobs pay less due to the lack of credentials despite the degrees they require. A job that was available to a Bachelor level practitioner just 7 years ago now requires a Masters degree, yet the job pays the same. I went back to school to try and raise the glass ceiling I had hit in my career. After graduating with my Masters in Social Work (MSW), I applied for mid-tier positions. I was told I was under qualified despite 5 years of experience and my new degree. Furthermore, many of these jobs are in large companies or not-for-profits which are steeped and embedded in White Supremacist systems and continue to employ oppressive tactics. Continually having to inhabit these White spaces results in supervisors, managers, boards, directors and CEOs who typically do not know about the histories and experiences of Black people and is at best tiring and worse harmful. From being tokenized, to being passed over for promotions, to being talked down to, to being unable to get adequate support for race-based issues with clients and co-workers, many Black providers struggle to navigate these added stressors, especially when combined with high caseloads, vicarious trauma, and burn out. The “Pet to Threat” phenomenon, where a person with a marginalized identity goes from being beloved in the workplace to despised once they excel, is also very common in the field and further pushes Black providers to the fringes or out of practice completely.
What Black Providers & Communities Need
The mental health field prizes Whiteness, money, and disconnection from the communities you serve. Research has shown that Black clients generally prefer providers who connect on at least some personal level. Therefore, Black clients frequently report struggling with White and other Non-Black providers. These struggles are why Black people need and increasingly are looking for more Black Providers. Furthermore there is research, which suggests that the additional understanding and solidarity when Black clients see Black providers is therapeutically beneficial. Another study shows that African-centered practices also have a powerful positive effect in treatment.
The desire to connect on a human level with clients can prevent Black providers from being accepted and trusted in the field because we get labeled as lacking objectivity or being unprofessional. Thus, Black providers frequently find themselves at odds with the norms of the field that still harken back to root of white saviorism and visiting helpers. Even the diagnostic criteria and treatments that we are sold as gospel and gold standards, are poisoned without the application of anti-oppressive and anti-racist lenses. This is because the research used to establish and validate such standards still largely omits populations of color. Furthermore, the treatment methods, especially behavioral and manualized therapies, frequently ignore vital socioeconomic contexts.
As if it is not bad enough to be in a field that is supposed to heal but is still rooted in the harm of our people, Black providers are typically grappling with these realizations and dilemmas alone. As mentioned earlier Black providers have been alone in our critiques since the start of the field. We had to establish our own groups and publications because the general (read: White) groups that were in control refused to listen and consider Black work. This continues today: Non-Black psychiatrists are still diagnosing Black clients with delusions when the client discusses experiencing racism, and providers are still labeling Black clients as resistant and aggressive because of a lack of cultural humility. These same people are our co-workers, they own the companies we work for, they are our supervisors, and just like they are dangerous to Black clients, they are dangerous to us and shape a field dominated by treatment-resistant workplaces that are in denial about their race problems.
With all these challenges, some Black providers leave the field. Others leave direct service to teach, train others, or take on consulting. Those that stay will frequently go into business for themselves to escape the microaggressions, pet-to-threat dynamics, and pressures to conform to standards that harm themselves and clients who look like them.
The Path Forward
If we really want to increase the ability for Black people to get good care from Black providers who are not co-opted tools of White Supremacist systems and/or burnt out, we must change how the mental health field functions from training to independent licensure. The present system prevents Black people not only from getting care, but also from being able to provide it to our own communities.
While the history is dark, there is hope because there is now more widespread awakening to the issues and barriers facing Black people. With focus on the issues there are more places and people with power interested in the solutions. Solutions like, adding mandatory coursework and continuing education for all providers could get the discussion started and help to start transforming workplaces into places that support Black wellness. With the pandemic making telehealth pervasive, there is also renewed interest in permanent interstate license reciprocity. Having licenses that are valid in all states would also help increase access to Black providers in areas where there aren’t many or any. Many people agree that changing leadership structures to include more Black people on boards and in other positions they have historically been locked out of could help. As mentioned above, offering training in African-Centered practices and theories could also benefit providers and clients alike. A solution that has gained a lot of traction is workplaces becoming actively anti-racist, which includes pay equality, giving employees a voice, and providing consistent and ongoing training among other things. Overall, the work to increase availability of services for Black people requires that we also make the path to providing services accessible and sustainable for Black people. Black providers need our colleagues to join us so that we can truly start to heal our society.