Therapy by and for Black Women

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This article appears in the June 2022 issue of The American Prospect magazine. Subscribe here.

Ebony Butler has wanted to be a psychologist since she was in high school. She pursued it through years of study, and then spent her entire career in the field, consulting for major hospitals and private health care companies. It’s an impressive résumé. But it never stopped her clients and colleagues from periodically lobbing criticisms at her—about her hair, her social media presence, even her intelligence.

The microaggressions were commonplace and predictable, but not debilitating. In 2020, however, a mass pandemic and a slew of racially charged murders upended Butler’s ability to practice psychology.

During this time, she experienced the same sleeplessness and hopelessness that millions felt. But as a Black woman at the professional and personal intersection of mental health, racism, and trauma, Butler had no moment of respite in her life.

Demand for therapy increased dramatically in 2020, and she soon realized how difficult it was to treat people when she struggled with the same emotions. Her solutions included personal therapeutic interventions such as talk therapy and meditation, so that Butler could “show up genuinely” for her clients, who are mostly Black women.

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Experiences like Butler’s are not uncommon. The dual pressures of being a Black woman in a systematically racist and sexist society mean that all Black women can require some sort of therapy or coping mechanism for the constant trauma inflicted. That includes even those who offer therapy to others for a living.

High-profile racist incidents of 2020, like the murders of George Floyd and Breonna Taylor, and the subsequent protests and trials that were mass-broadcast, made racism ubiquitous and unavoidable. It raised awareness of how these racist incidents impact not just the victim, but entire communities that feel kinship to the victim. Researchers and mental-health practitioners—especially BIPOC ones—have been aware of this phenomenon, known as racial trauma, for decades, but the events of 2020 increased interest among the scientific community.

The unique effects of racial trauma on Black women raise the need for therapeutic interventions on a significant portion of the population. The Black female practitioners at the forefront of understanding and developing this field know personally that racism and sexism compound and often bleed into everyday life, and they contour their treatment of other Black women accordingly. Left to neglect, racial trauma can spill over into physical health, as the burden of being Black wears down the body. That catastrophic consequence demands urgent, race-conscious treatment.

RACIAL TRAUMA IS THE STUDY of how racially sensitive incidents impart PTSD-like symptoms, such as depression, anxiety, and anger—all of which spiked among Black Americans after George Floyd’s killing, according to a study published in the journal Proceedings of the National Academy of Sciences.

A 2021 study published in JAMA Psychiatry put some science behind the concept. Black women who had self-reported racial discrimination showed a “disproportionately greater response in brain regions associated with emotion regulation and fear inhibition and visual attention.” Put another way, Black women with this experience may exhibit hypervigilance to sensitive situations, especially those with a racial component. This increased threat vigilance can be tied to high anxiety, depression, or other PTSD-like symptoms.

Racial trauma is the study of how racially sensitive incidents impart PTSD-like symptoms, such as depression, anxiety, and anger.

The study also confirmed what Negar Fani, lead author on the study and professor at Emory University, has been observing in her career: Trauma does not necessarily lead, as researchers have long accepted, to less ability to pay attention. Instead, the study demonstrates that victims of racial trauma expend more resources to maintain a state of concentration when they are faced with racially triggering stimuli. Fani described it as “working twice as hard to get just as far.”

The JAMA study reflects part of a shift within the scientific community about both the concept of racial trauma and its real-world implications. As recently as 2020, studies like this were largely dismissed or ignored. “This work was really unpopular,” Fani said.

But over the past decade, as racially motivated events were repeatedly shared across social media and other channels, from Michael Brown to Philando Castile, it became harder to leave this area of psychology disregarded.

Thema Bryant-Davis, president-elect of the American Psychological Association (APA), noted how these early studies are important to spur further research, in terms of both funding opportunities and credibility. “It was important to document the neurological impact of racism,” she said, “to understand that stress and trauma include impacting the body [and] the brain.”

Bryant-Davis published an early explanatory study on racial trauma in 2005, just three years after Hugh F. Butts published “The Black Mask of Humanity,” his seminal piece on the topic. Butts and Bryant-Davis’s articles, along with subsequent studies in 2006 and 2007, formed the early frameworks for understanding racial trauma. Butts presented case-by-case examples from his years of practice, and Bryant-Davis and fellow researchers made parallels to other types of trauma, such as domestic violence.

The nature of racial trauma makes it a particularly sticky ailment. “Covert racist incidents form the social backdrop against which racially marginalized people must function day to day,” Bryant-Davis and Carlota Ocampo write in a 2005 article, “The Trauma of Racism: Implications for Counseling, Research, and Education.” “The incidents are never far from one’s consciousness and require expenditures of cognitive energy, hypervigilance, and coping.”

Mass broadcasting the murder of George Floyd was not only traumatic because Black people watched a man who looked like them be brutally murdered, but because Black people had to subsequently hear that murder justified relentlessly, even after the conviction of the police officer who did it.

Many Black people felt not only their fear, but their community’s fear. And racist incidents that do not happen to an individual directly can still trigger a PTSD-like response in that individual, simply through them remembering their own personal experiences with discrimination.

In an article titled “Racist Incident–Based Trauma,” Bryant-Davis and Ocampo also speak to the dismissal of racial trauma, arguing that it “relieves researchers, counselors, and educators of their responsibility to alleviate suffering.” Seventeen years later, Bryant-Davis, along with the researchers and mental-health practitioners who followed her lead, are finally having their voices heard. “People are saying, ‘Well, maybe we need a framework,’” she said. “But the work has already been done.”

In 2019, the APA published a special issue of American Psychologist entitled “Racial Trauma: Theory, Research, and Healing” to study “the consequences of racial discrimination and also the factors promoting healing from racial trauma,” acknowledging the growing field and the rise in hate crimes, along with research on how racial trauma has historically affected different BIPOC populations.

The publication featured multiple premiere researchers and psychologists with insight into racial trauma over the years, and was co-edited by Lillian Comas-Díaz, a leading psychologist and researcher on multiethnic issues. “Cumulative racial trauma can leave scars for those who are dehumanized,” Comas-Díaz and co-editors wrote in the issue’s introduction.

The issue included both empirical research on the links between PTSD and racial discrimination, along with newer conceptual models for understanding racial trauma on a variety of populations, like interned Japanese Americans. One study detailed how the prevailing idea of “acculturation,” or how minority groups integrate, has led people of color to “avoid racial discourse” to minimize backlash, which is harmful when trying to treat racial trauma.

The recent acknowledgment of racial trauma as a scientific reality means that for decades upon decades, Black people have been coping with this incessantly racist society however they have been able to. And the effects are not just mental, but physical.

EARLY THIS YEAR, Butler left the public sector, opening up a private practice in Austin, Texas. The Black women who see her express feeling undermined, dismissed, and consumed with fear, such as the fear of other people or the fear of saying no. Black women must also constantly field microaggressions about their hair, attire, and attitude.

But the most consistent issue Butler encounters involves Black women overcommitting and overextending themselves. Researchers and practitioners have been positing that this “Strong Black Woman schema” contributes to a multitude of health disparities, especially through the mechanism of stress. Black women who internalize the need to do everything and take care of the community feel heightened stress, and they may neglect their physical or mental health.

“When people have experienced trauma, they’re more focused on the trauma that’s happening to somebody else rather than the trauma within themselves,” Butler said. “You don’t give yourself a lot of opportunity to deal with your stuff, especially as a therapist.”

This untreated stress manifests within the body and mind. “Racial discrimination is a toxic … stressor that is associated not only with poor physical health but also with psychological stress,” states an article in the Journal of Women’s Health, published in early 2021. “Chronic stressors reduce coping resources and increase vulnerability to mental health problems.”

The JAMA study concluded something similar, stating that frequent racism may “lead to heightened modulation of regulatory resources,” potentially representing an “important neurobiological pathway for race-related health disparities.”

What these studies indicate is that a person only has so many resources to allocate within a given period. When racial trauma is happening to an individual nearly every day, those resources may be directed that way instead of toward maintaining one’s health. This can be true whether a person is actively railing against racial stress, or if they are shielding themselves from it.

For many, the stress is constant, which can lead to elevated levels of the hormone cortisol. Elevated levels of this chemical are associated with various negative health outcomes, including high blood pressure, high blood sugar, and mood issues.

The theory can help explain the high rates of physical ailments among Black women, such as heart disease or anemia. High blood pressure, a gateway to broader negative health conditions, is more commonly developed in Black people. One remarkable study from 2018 showed women of color feeling discrimination during prenatal care, and passing that chronic stress on through the womb, resulting in higher rates of premature or underweight births.

The disparity in health outcomes was most conspicuous during the COVID pandemic, with one study finding non-Hispanic Black people suffering 34 percent of COVID deaths despite being 13 percent of the population. Researchers have connected higher COVID death rates in Black men to the cumulative effects of stress from being Black in America.

Butler has found that her clients complain of chronic pain and inflammation, along with mental issues such as anxiety, depression, and general stress on the nervous system. She has found that her own experiences with some of the same ailments help her connect with her patients, but also that sometimes it does not matter. Black people understand inhabiting a Black body in this world perhaps more than anything else.

“People feel like I would understand even if I don’t understand,” Butler said. “They don’t have to explain nuances to me.”

This comfort cannot be overstated. It causes people to actively seek out therapists who will understand them—an issue for Black people, as only 4 percent of psychologists were Black as of 2015. It is why websites like therapyforblackgirls.com or blackfemaletherapists.com exist.

Therapy for Black Girls is where most of Alena Bell’s clients have found her. Bell is a licensed marriage and family therapist based out of the Bay Area, where she was born and raised. She has spent her entire career as a psychotherapist treating trauma in Black people—be it the Black youth she worked with in her practicum, or the formerly unhoused Black people she worked with at the University of California San Francisco at the beginning of her career.

She transitioned to the private sector in 2019. After a maternity leave, Bell is back to primarily serving Black people, especially professional Black women.

“Every client of mine has experienced some racial trauma, just by essence of being a Black person in [this] country,” Bell told me.

The professional Black women Bell serves often deal with complex and developmental trauma on top of the racial trauma. Bell also finds that her clients, often in high-functioning positions, may find themselves the only Black woman, or even the only Black person, in the room, when they are not used to that.

This also leads to an unhealthy dose of self-doubt, according to Bell. Black women frequently find themselves questioning whether something was really profiling, or targeting, or just racist.

MOST STUDIES IN RACIAL TRAUMA have focused on proving the phenomenon rather than determining a treatment. There are no tried-and-true models like the tactics used in treatment of PTSD.

This is partially due to medical and scientific fields being infamously racist. Black women have been medical guinea pigs in America since the time when they had no bodily autonomy, and they still face inequitable treatment. Despite health disparities that require more medical attention, Black women consistently report being ignored and dismissed by their doctors.

“A lot of trauma psychologists were not even trained to conceptualize oppression as traumatizing,” Bryant-Davis told me. “That has been a major gap in the field that is really rooted in racism.”

Butler is well-versed in different modalities of therapy, including cognitive behavioral therapy and its offshoot dialectical behavioral therapy, forms of talk therapy that involve assessing triggers for mood and trauma disorders and developing coping strategies. “But a lot of those trauma modalities or treatment interventions have not been normed for Black folks,” she told me.

Butler’s approach often ends up being a “relational approach,” where she pulls from different methods to treat individual cases. Sometimes this means helping a client develop mechanisms for diverting harmful thoughts; sometimes it means helping a client practice grounding techniques that bring them back to the present moment and away from reliving trauma. But it always involves validating a person’s experience.

Doubt is part of what makes racial trauma so insidious. Black people in America have been both constantly subjected to the racist nature of the country, while also being told that there is no racist nature. It is gaslighting at its finest, and it means that Black people who experience trauma must be validated before they can be properly treated.

Candice Hargons is an associate professor at the University of Kentucky and founding director of the Center for Healing Racial Trauma. She developed her own methodology for treating racial trauma, which includes validating racist experiences, affirming the humanity of her clients, and helping them develop a routine of self-care. In treating race-related stress, Hargons has “seen Black women come to realize a positive sense of themselves and gain more confidence, learn how to advocate for themselves intentionally, feel healthier, and act in ways that are healthier in their relationships.”

Therapy is often critical to self-care for Black women. While the National Alliance on Mental Illness reports that only 1 in 3 Black adults who need therapy receive it, Bryant-Davis told me that “Black women are more likely to seek therapy than Black men.”

With such a low incidence of Black therapists in the United States, Black women often find it difficult to find therapists who look like them, and end up settling for non-Black therapists who do not understand them on a fundamental level. A therapist who is unaware of their own biases and cultural blind spots might actually inflict more harm on a Black woman than they do to mitigate it.

The APA’s Race and Ethnicity Guidelines from 2019 say that in order to provide services without bias, psychologists need to consider “race, ethnicity and culture” in treatment and assessment. In 2021, the APA adopted a resolution to apologize for its legacy of promoting racism, stating, “APA acknowledges that recognition and apology only ring true when accompanied by action; by not only bringing awareness of the past into the present but in acting to ensure reconciliation, repair, and renewal.”

Non-Black therapists can be allies and advocates for Black women the same way that Black therapists can, if they are willing to put in the work to both understand their clients and be culturally and racially aware themselves.

Therapy still will not work for everyone, nor will everyone have access to it, especially given economic disparities among people of color. And many Black people must overcome a stigma perpetuated by both their communities and general cultural attitudes toward therapy.

Throughout history, Black women have had to advocate for themselves. Forgotten from the civil rights movement and dropped from the women’s rights movement, Black women have consistently had to pave the way for rights for themselves and everyone. Many Black women internalize this narrative and the idea that they should always be doing more; that’s part of the Strong Black Woman schema and the source of some stress. Black women who attend to their mental and physical needs as a priority are doing all that they should.

In Butler’s unique position, she has to constantly practice setting boundaries with people around her and listening to her body and mind signals. These are techniques that many Black women can benefit from, no matter their profession.

Treating racial trauma is not just a personal endeavor, but a communal one. Communal healing is impeded by the historical hurdles to get the public to internalize the harms of systemic racism. “People are willing to acknowledge an individual incident as traumatizing, but not the violation of an entire group of people,” Bryant-Davis told me.

Attitudes seem to be shifting in the past few years, with a rise in conversations about mental health and the need for self-care. As Comas-Díaz told me, “Self-care is collective care. You’re taking care of your community.”

IT IS PERHAPS NOT SURPRISING that Black women and other women of color have led the research on racial trauma. They have worked relentlessly in what has been a thankless field for years, and only now are they starting to see Black women actually benefit from their work.

And there is still more work to do. The basic acknowledgment of the reality of their trauma is only the beginning. Most Black women cannot wait for scientific and medical communities to validate their experiences, as racism is ongoing, and racial trauma accumulative. That is why the BIPOC researchers and practitioners continue to dedicate energy to untangling this concept, while they advocate for their own health.

“Advocacy is a huge way I continue to take care of myself,” Butler told me. By being proactive with all aspects of health, Butler can hold an open and honest space for the Black women who come to her, especially the ones who have to start at square one. Racism may never end, but at least its harm to a Black woman’s mental and physical health can be mitigated.

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