Race and Therapy
Patients and practitioners try to understand the role of race in mental health care
Andrea K. Castillo was born in 1986 in the diverse Kensington section of Brooklyn, the youngest of four children. Her parents had emigrated from Belize City in the 1970s. First they had an apartment, but by 1995, they moved into a wooden house that was almost identical to the other ones on the street.
Castillo was always the “good one.” Her three brothers were much older than she was, with her closest brother five years ahead. Still, they always found ways to include her. They taught her how to play video games and introduced her to their favorite rappers. She had a creative side — she had a strong fashion sense and knew how to arrange a photograph — and her brothers encouraged her, albeit sometimes in self-serving ways. The three boys had a shoplifting business. They would go out and steal designer brand clothes and sneakers. When they returned, Castillo, a skinny seven-year-old with a curly black bob, would come to their rooms and examine their plunder. She told them which shirts to wear with which sneakers. Then, placing props in a makeshift set, she would ask them to strike dynamic poses and shuffle into position between the crosshairs of her camera’s viewfinder. Those photos would be printed and disseminated by her brothers as advertisements to their fellow classmates, who would buy their favorite items.
“I was like basically their Instagram photographer before Instagram,” Castillo said.
Those experiences became haunted memories in the years that followed. By the time Castillo was a teenager, her two elder brothers, Dylan and Ben, were ensnared in the criminal justice system, drifting in and out of jails and prisons for various misdemeanors and felonies. Will, the youngest brother, did not end up with a criminal record. But he did get diagnosed with paranoid schizophrenia at the age of 18, and Castillo’s parents sent him to a group home.
Ben, the middle brother, struggled the most. “The first time I remember him getting locked up and being taken away to a juvenile center was when he was 13,” Castillo said. “So I was six.”
It was the beginning of a struggle that would last for years. “He missed all my birthdays from 13 to 21,” she recalled. It was not because he was incarcerated that entire time. He would get out, and then shortly after he would go back in. “For years, I would document my birthdays in how many times he wouldn’t be there,” Castillo said.
Castillo’s parents kept mostly silent about her brothers’ troubles. “My parents wouldn’t really even talk about it with other family members,” Castillo said, “So I’m thinking, if they’re not mentioning it to my aunt, uncle grandma, and grandpa, then I probably shouldn’t say anything.”
Therapy never came up as an option for any of them. The only therapy they encountered was the mandatory counseling that Dylan and Ben received at the hands of the state and that Stephen received in the group home. The only other people Castillo saw receive mental health care were “those hyper white boys” from school. Students whispered about their disrespectful behavior toward teachers and later gossiped about how those boys had to go to therapy.
Castillo’s family was from the Caribbean, where historically many psychiatric asylums acted as punitive arms of colonial governments. Like other families of color from countries that survived colonialism, her family treated mental health as a taboo topic.
Therapy never came up as an option for any of them. The only therapy they encountered was the mandatory counseling that Dylan and Ben received at the hands of the state and that Will received in the group home. The only other people Castillo saw receive mental health care were “those hyper white boys” from school. Students whispered about their disrespectful behavior toward teachers and later gossiped about how those boys had to go to therapy.
In her senior year of high school, she finally told her two closest friends. It turned out they both had family members who were incarcerated. “Everyone has somebody,” they told Castillo. Yet, no one had ever said anything.
In college, Castillo began to open up more about her brothers’ incarcerations. Anticipating Ben’s release from a six-year-long prison term near the end of her senior year, she sought advice from a visiting scholar who came to an event for the students of color coalition. The scholar recommended therapy to help Ben adjust to the free world. He would have to learn how to use a smartphone and navigate the new MetroCard system. He would also have to reintegrate into familial dynamics and dormant friendships.
It seemed like a good idea. Her curiosity sparked, Castillo made an appointment at the school’s counseling office to see what therapy was like. As she answered the intake questions (Do you have frequent feelings of guilt? Describe your childhood. Have you ever experienced extreme anxiety?), she was embarrassed by how little insight she had into her own past. She went back for one more appointment, and then never returned. She had other things to do in those last hectic days of college.
After graduating in 2008, Castillo moved back home and began a freelancing business as a photographer and writer. Her entrepreneurial streak made her well suited to the age of social media. A skilled tweeter, Castillo posted as @andreakcastillo about everything that caught her interest, from Belizean gender roles to the latest Black-owned business. She gained a following that even included Barack Obama’s Twitter account. In 2011, she created a blog called A Life in the Day of Andrea. Soon afterward, she started a business called Cas Rum Beverages that bottles Belizean style rum cocktails. That year she also started a year-long paid staff writer position covering local musicians for a website called Concrete Loop.
Splitting her time between creative gigs left little room for recuperation. Then, Concrete Loop shut down. Castillo worked administrative jobs while trying to find paid creative work but was thwarted by a constant undercurrent of anxiety. One day she was even sent home from her day job as a receptionist. She went to a cardiologist who told her that she needed to “relax.” She left the appointment feeling annoyed and dismissed.
She was dealing with ordinary problems — anxiety about jobs and lengthy to-do lists. But there was also something else. She still had unprocessed memories of her childhood, her brothers’ absences, and the deafening silence with which those problems were met at home.
The cycle continued. “I was dealing with so much,” she recalled. “Losing jobs, getting jobs, losing jobs, getting jobs, really unstable romantic relationships.”
And then, in 2013, something snapped. She was at her computer trying to write a blog post, but different things she had to do kept popping into her head. Suddenly, she said, “I felt this huge pressure on my chest.” She hunched over crying under the sloping walls of her room in the attic of her parents’ house, where she still lived as she was trying to get her business off the ground. Her parents were home, but after years of not talking about the thick emotional climate that enveloped them all, she did not see the point in trying to explain herself to them.
The next day, she pulled open her laptop to look for a therapist. “I just didn’t know where to begin.”
“Therapist” is an umbrella term for clinical psychologists and social workers. Though on the surface their practices look similar, the two professions have different roots. Psychology grew out of philosophical and medical paradigms in the 19th century, the most significant of which was Freudian theory, which focused on familial and sexual relationships above all else. Social work, born in the same period, emerged as a kind of social experiment in which volunteers devised programs and settlements that were aimed at alleviating poverty.
The professions still have their differences today. Psychologists tend to have a diagnostic specialty — for example, borderline personality disorder in adolescents — and think about their clients’ problems in terms of developmental stages (e.g.: parental relationships, early trauma). Social workers are trained to consider how social conditions — poverty, marginalization, and oppression — shape mental health.
Of the two professions, psychology has the reputation for being more white. According to 2015 data from the American Psychological Association, 86 percent of psychologists in the United States were white, 5 percent were Asian, 5 percent were Latinx, and 4 percent were Black. Social work schools — which can be completed in 2 years (as opposed to 6 years to earn a psychology doctorate) and cost less — tend to draw a more diverse student body. A 2017 report from George Washington University estimated that 70 percent of social workers were white, 3.6 percent were Asian, 11 percent were Latinx, and 22 percent were Black.
But for most people seeking a therapist, the distinctions between the two strands of therapy are largely irrelevant. Once someone has decided to try out therapy, the next hurdle they have is cost. Most therapists do not accept insurance because reimbursement plans often under-compensate psychotherapists and/or provide unrealistic treatment plans that only budget a few visits for complex problems.
People of color face the additional barrier of navigating a predominantly white mental healthcare system that has a reputation for mistreating them. Latinx and Black patients get over-diagnosed with mental health problems. And a study in 2016 showed that white therapists were more likely to call back white patients for appointments over Black patients.
In his 1995 book, The Influence of Race and Racial Identity in Psychotherapy, Robert T. Carter, an emeritus professor of Psychology and Education at Columbia University, explored the racialized history that lurks beneath today’s mental health disparities.
Those disparities can be traced back to the nineteenth century, when American psychology underwent an institutionalization, legitimated by its own professional associations and academia. Psychologists’ writings before the Civil War used medical literature to affirm enslavement and render Black communities as unable to mentally withstand freedom. Black people escaping to freedom were diagnosed with mental illnesses and the census contained since debunked findings that mental illness was 11 times greater in northern Black communities where slavery was illegal.
From the emancipation into the early 20th century, studies published in both the north and south extended the narrative, suggesting newly free Black communities had rampant mental health problems. The eugenics movement saw its peak in these years as well, with 33 states adopting sterilization programs.
The medicalization of racial inferiority fueled resistance. A wave of Black social scientists, social workers, and psychologists like W.E.B. Dubois infused their own research, rife with anti-racist counter-narratives, into the academic bloodstream. But it was only after the Holocaust that biological arguments for racial inferiority began to subside in earnest. People of color, who were experiencing new waves of economic mobility, sought out mental health services and became practitioners during the 1950s. Their contributions and the rise of the Civil Rights movement inspired a wave of clinical literature that espoused universalist views of people as more similar to one another than different.
Colorblindness, however, was a double-edged sword. It acknowledged past injustices without necessarily understanding their continued presence in people’s lives.
It was only in the 1980s that practitioners like Elaine Pinderhughes began to unseat colorblindness from its pedestal. Her Understanding Race, Ethnicity, & Power became a signature text in psychological curricula. The book argued that race infiltrated every aspect of American society, including therapy, whose practitioners should interrogate their own identity as a factor that could shape their interactions.
Still, longstanding cultural ideas like racial inferiority are not bounded neatly in decades. In 1994, psychologist Richard J. Herrnstein and social scientist Charles Murray published The Bell Curve. Lauded in the New York Times and The Wall Street Journal, the book argued that Black people had lower IQs and were threatening the nation’s wellbeing by reproducing faster than other racial groups.
Today, The Bell Curve seems like a distant nightmare. The racialized history that made it possible, however, persists for people of color seeking therapy in a system ill equipped to acknowledge their experiences.
Some researchers think the most important next step towards addressing this problem is to include racial trauma in “The Diagnostic and Statistical Manual of Mental Disorders” (DSM–5) — the authoritative text that all mental health professionals use to diagnose patients. According to a paper co-authored by Monnica T. Williams, a clinical psychologist and associate professor in the School of Psychology at the University of Ottawa, micro-aggressions and anxiety over time can make a client vulnerable to reaching a breaking point and manifesting symptoms of PTSD.
The reason including race in the DSM-5 matters, she says, is because a lot of clinicians “don’t think it’s real unless it’s in the DSM.” Including racism as its own category or a subcategory of PTSD, she says, could help white providers better understand racialized experiences and pursue effective treatment plans.
For the clients who would rather not navigate cultural divides, there are online directories — such as Therapy for Black Girls, Latinx Therapy, and National Queer & Trans Therapists of Color — where people can find therapists who match their needs in certain cities. A newly launched social and wellness club in Brooklyn, Ethel’s Club, aims to be an in-person version of these directories. The club has been described as a Black and brown version of The Wing, a women’s co-working space. But unlike the Wing, Ethel’s Club has a plethora of wellness offerings, one of which is an on-site therapy program. Members have access to a list of therapists. They can schedule 15-minute in person consultations with them on site. After the initial meeting, they can choose whether to become a client.
Those who don’t live in cities or cannot pay the membership fee at Ethel’s Club, however, must rely on psychotherapy as a field improving its cultural competency. And, to be fair, therapists are working on it. Trade publications, academic centers, professional associations, and blogs are full of articles coaching white therapists about cultural difference, micro-aggressions, and diversity. In one of them, “November 8, 2016: The day I became a White clinician,” psychologist Susan Bodnar wrote about how, in the wake of the Trump election, she was forced to talk about her whiteness with Black clients in order to retain them in her practice. Some of them, she writes, left anyway. In their final session, one of Bodnar’s teenage clients said, “Sorry. I can’t help it. You’re nice and smart and you helped me a lot. But right now you are a white person. I can’t trust you, the world you came from, because that world is equal to the death of me.”
Therapists call this feeling — a total loss of trust in the clinician — “rupture.”
When it’s racial, one of two things usually happen. Clients either quit therapy altogether or they seek out a therapist of color.
But in a field that is still dominated by white therapists, where racism is still not an explicit diagnostic category and race is not yet an identifier by which most providers (nominally still colorblind) sort themselves, this is not so easy.
Castillo looked for a therapist intermittently for weeks. As she scanned dozens of webpages, she mainly sought providers who took insurance. But she also wondered how she would feel opening up to each one about how her family history had affected her mental health.
The first appointment she made was with a therapist in Flatbush, a predominantly Black neighborhood. When she walked in the door, she was disappointed to see that the therapist was white. She sat down and the therapist began asking her a laundry list of intake questions about her mental health history. Castillo found herself feeling defensive.
She was not sure what to think until the very end of the session, at which point the therapist told her that she had to make an appointment with a psychiatrist.
“I’m like, you want to drug me, and I don’t have a condition?” said Castillo, a flash of indignation crossing her face. “Or, there’s no diagnosis of a condition but you just want money off me from a prescription I don’t need?
“I never made that appointment.”
It was one of those bad, clarifying experiences. The interaction had felt so “transactional.” What was missing, she realized, was trust. It was hard to believe that this therapist, rushing through her questions, actually understood Castillo’s answers. It was hard to believe that this white woman could empathize with what it had been like to send letters to an older brother in prison about how much you missed him, only to have it be returned because one digit in the prisoner identification number had been wrong. It was hard to believe she’d understand how frustrating it was to feel angry with another brother after spending years awaiting his return. She went home and cracked open her laptop again. This time she Google searched “Black therapist near me.”
“I wanted a therapist of color,” she remembered, “because from a statistical standpoint this person I feel would better understand me. There’s a higher chance that they have family members that were incarcerated or they know someone or they have a friend that knows someone. Maybe it is a conversation or maybe it’s not, but we know that is a reality.”
She made a new appointment with a Black therapist near her neighborhood. When Castillo passed through the office’s glassy threshold, she smelled incense, and noticed a small retail area near reception that sold essential oils and manifestation candles. It took off the medical edge of the place; she felt more at home.
When she met her therapist, the connection was instant. Their conversation flowed naturally. Her therapist was also raised in Brooklyn, in a Jamaican-American family. The conversation was light at first. They laughed and talked openly about their cultures, food, growing up in New York City, and the art of passing a driving test.
“For me that was really one of the first times I felt seen because I didn’t have to explain myself to her,” Castillo said. As she opened up about her experiences with her brothers’ incarcerations, she noticed that that sense of familiarity remained. “I don’t think she had to deal with that firsthand,” said Castillo, “but she understood it and it was kind of a normal conversation to have as opposed to like a very prodding conversation.”
Castillo kept seeing this therapist. She even became an advocate, of sorts, among her friends, for therapy, and especially for therapy with therapists of color.
Clients of color who bring race-related experiences to therapy need to have a sense of what Ieasha Ramsay, a Manhattan-based social worker with a private practice serving young professionals of color, calls “shared reality” with their therapist. To help them develop coping skills and strategies, therapists have to see the racialized world that their clients experience.
Ramsay says that many of her clients work in predominantly white spaces, where they bear the burden of “double duty,” performing both as advocates for diversity and victims of workplace oppression. They endure discriminatory comments and insensitive questions. They are passed over for promotions despite stellar performance reviews. They are confused with Black co-workers. Embedded in their work is a noxious quid pro quo. In exchange for employment, they endure racism.
The buildup of these experiences, Ramsay says, can cause “functional depression.” Although clients get out of bed and go to work, they tell her, “I’m zoning out in my meetings,” or, “I’m crying in the bathroom at work.”
Monnica T. Williams, the psychologist advocating for revising the DSM-5, says that these experiences are on a spectrum whose extremes can be quite scary. She described one client that she recognized as suffering from racial trauma. The client, who was Black, told Williams a harrowing story about an after-work dinner she had with a white colleague while she was on a business trip. They were both directors at a large, well-known company. He spent the dinner “telling her about his violent exploits” from his previous stint in law enforcement. His behavior suggested to Williams’s client that he was threatening her with violence if she did not sleep with him. At the end of dinner, she remembered him saying, “If you tell anybody, I’ll bury your body so deep, no one could find it.”
By the time she returned to her hotel room, she was terrified. “She sat up all night in her bathtub with a knife,” Williams said, “thinking he was going to come for her.”
The man was fired after the woman reported the incident, and she was assured that the company’s security team would protect her. But when she went to work the next day, no one had been.
It was the last straw. Williams’s client was so scared that her ex-colleague would exact revenge that she became “incapacitated.”
At the time, Williams was a relatively young member of a widely respected team of PTSD experts at the University of Pennsylvania. When Williams presented the case in a meeting to her colleagues, they didn’t see what the problem was. “They were like, ‘Well, it was just a conversation after work. How could that traumatize someone?’ They didn’t understand the layers that were embedded in this conversation and all the different ways that it assaulted her sense of safety and self-esteem.” It was the first time Williams understood the importance of improving psychotherapists’ tools for detecting racism and treating it. She wanted to help her white colleagues see racism not only when it was expressed overtly as epithets, but also in situations like these, where it was part of body language, workplaces, threatening statements, and other power dynamics that harmed patients of color to varying degrees every day.
The workplace, unfortunately, is only one of many serious threats to clients’ sense of safety, says Julian Cabezas, a social worker with a private practice serving queer and trans clientele of color. He says that his immigrant clients talk often about the Trump administration in therapy. They fear deportation, having their visas revoked, and being brutally attacked.
The art of building a space where clients can both talk about themselves and the racialized power dynamics they experience is a delicate one. It involves numerous conversations, all linked together in a concerted effort to forge a new future from a lifetime of frustration.
But what happens when therapy itself is the frustration? When therapy is being forced upon a client by the state?
Brian Valentine is a therapist at Help to Adjust Counseling and Anger Management, which mainly serves Black and Latinx clients. The practice offers a nine-session therapy program that fulfills court-ordered anger management requirements. Some clients, who to an extent are more fortunate that Castillo’s brothers, are there in lieu of jail time. But not everyone in the group comes in with an anger problem. Valentine suspects that at least some of the clients are there because their white boss or a police officer has unfairly read their behavior as threatening. For this group, he does whatever he can to make their nine mandatory sessions together a worthwhile experience.
But for those of his clients who come to therapy with an obvious anger issue, Valentine responds differently. He had one client who tried to bribe him to get out of anger management. Valentine said no. Then he invited the client to sit down and talk. The client had recently snatched a phone out of a stranger’s hand during an altercation and smashed it on the ground.
“He didn’t think that was a big deal,” Valentine said, “because he didn’t fight them. He didn’t assault them. He didn’t beat them up.”
Valentine says that clients with obvious anger issues are often immersed in circumstances where “destructive behavior has been normalized.” For these clients, the goal is simple: develop insight into how they feel and how they look to outsiders. And managing outward appearances, especially given how police brutality can target Black and brown men, is a safety issue.
Valentine and his clients are on the edge of a thin social safety net. For working class, mentally ill people of color who are not being shuffled through the criminal justice system, city hospitals are some of their only mental health resources. They serve New Yorkers known by medical professionals as “the people no one wants to take care of.” That means immigrants and marginalized populations who are dealing with HIV, substance abuse, and sexual health issues.
Those patients are often forced to rely on underfunded, understaffed, and neglected mental health services. Overburdened social workers are responsible for far too many patients. Some clinicians burn off frustration by making off-color jokes about their own clients. Medical charts are filled out poorly. Armando Fuentes, a psychologist who worked at one such hospital, said that once when the emergency room was overloaded with patients, doctors put a severely mentally ill woman in a room that was leaking from the ceiling. That is nowhere near as bad as it gets. Other city hospitals have sexually and physically abused their mentally ill patients.
Outside of city hospitals, the mental health landscape is dotted by clinics, including for-profit ones that provide solid mental health resources for working class New Yorkers. But even in these spaces, the scale and complexity of the problems that patients face breed burnout among clinicians. Ieasha Ramsay, who started her career in one of these spaces, crystallized this cycle of passion and despair.
“There was something about the way that substance abuse crosses itself with race,” says Ramsay. “It’s really raw. People are getting their children taken away and then losing their housing, and they’re struggling with addiction because they do not have any coping skills and there’s no resources in their communities to develop coping skills. And so I just got a really personal and transparent look at how the system just fails a certain group of people over and over again.”
But Ramsay soon realized that neither she nor the clinic could break the systems that pinned her clients down.
“It was also really hard to work in those spaces knowing that no matter what work we do together, I still can’t get you an apartment. No matter what work we do together, I can’t stop you from living in the neighborhood where a guy’s selling whatever he’s selling on your corner. It became really discouraging to go to work every day and see my clients do amazing things in this session with me, but then have to go out and get pinned up against the wall by a police officer. And I can’t do anything about it.”
For practitioners and patients in these situations, therapy can only be a coping strategy. It will not be a solution.
I met Castillo at the opening celebration for Ethel’s Club, the wellness and social club for people of color. At the party, she mingled with other attendees in trendy, well accessorized outfits. Books and artwork by bell hooks and Adrian Paper were placed in sculptural configurations on shelves throughout the sparsely decorated warehouse. Colorful couches and seating lined lounge areas. Along the walls were shelves with different snacks and beverages from brands owned by people of color. One of them was Castillo’s Cas Rum Beverage.
The therapy program was the seed of Ethel’s Club. The club’s founder, Naj Austin, had herself been unable to find a therapist when she was in her mid-20s. It wasn’t the money or the insurance. It was that she wanted a therapist who was a person of color. But the search was difficult. She did not feel comfortable asking her friends, and websites like ZocDoc, which connect patients to nearby, in-network doctors, did not let her filter providers by race.
Frustrated, she began imagining a solution. “I thought it would be compelling if you could meet with therapists of color inside of a beautifully-designed space,” Austin told the Powerbitches gather website. She began fleshing out other things that that beautiful space could hold. And so Ethel’s Club was born.
The idea quickly garnered attention. It raised $25,000 in crowdfunding. Roxane Gay became an investor. On the first day that members could apply, in September 2019, a flood of applications crashed the website. Castillo’s was one of them.
Castillo said the therapy and wellness programs were among the main reasons she felt compelled to apply.
“I think we’ve all collectively figured out that we need to find methods to heal effectively and safely,” said Castillo. “And you know there’s so many ways in which you can do that, but sometimes you’re not necessarily supported in that space and you may not necessarily be seen in that space.”
Is a therapist who looks like you guaranteed to make you feel more “seen”? Of course not. But the alluring possibility of healing in the care of a Black or brown gaze seems to have struck a chord. At last count, the waiting list for Ethel’s Club was 4,300 people long.
Castillo sees the popularity as representative of a cultural shift.
“I had to learn about therapy on my own. And I definitely went later than I would have gone,” Castillo said. “But because I think I knew what I wanted to achieve since I’ve been in therapy, everything in my life has been on a fast track.” And then, laughing, she added, “So I think I’ve made up for the lost time.”
NOTE: Some of the names in this article have been withheld for privacy.
