In times as uncertain as these, it's no wonder that the nation's collective mental health seems to be suffering. According to a reader survey conducted by Women's Health, 70.3% of the 2,500 of you who responded said that your mental health had got worse since the pandemic began. Meanwhile, 85.2% are concerned about the long-term effect lockdown may have on yourself or others.
It feels like World Mental Health Day (10th October) couldn't come at a more prescient time. The theme this year is 'mental health for all'. The goal? To increase investment in mental health services, globally. This is important. According to the World Health Organisation (WHO), 'in low and middle-income countries, more than 75% of people with mental, neurological and substance use disorders receive no treatment for their condition at all.'
In this feature, originally published in the September 2020 print issue of WH, writer Tahmina Begum explores a key issue. Is talking therapy, at present, failing women of colour?
Is Talking Therapy Failing Women of Colour? WH Digs Into The Issue
The year Halima* turned 18 was memorable for all the wrong reasons. It was punctuated by anxious episodes so disabling that getting out of bed became a daily struggle. Her thoughts raced, her chest pounded, and after a few months of trying and failing to push through her feelings, she sought help from her GP. Antidepressants were discussed, then rejected. Talking felt... safer, and after an eight-month wait – during which time she had a number of in-person and over-the-phone assessments – Halima showed up for her first NHS therapy session. It wasn’t long until she realised it wasn’t working for her – and why.
‘Whether it was my Asian therapist on the phone or my white face-to-face therapist, both made assumptions about who I was when they found out that I was a Black and Arab Muslim woman who wore the hijab,’ she tells Women’s Health. ‘I fell into their stereotypes of being subservient and passive. It was as though I had to explain my way out of the lens they were viewing me through first in order to make them see me for who I was. Just because I’m Muslim doesn’t mean I’m quiet; just because I wear a hijab doesn’t mean I’m “oppressed” by my ultra-strict parents.’
So negative was her experience of therapy that Halima left after four sessions. She tempered subsequent bouts of anxiety by practicing self-care; she hasn’t returned to therapy since.
Research suggests that Halima’s experience of talking therapy isn’t an isolated one. An independent review of the Mental Health Act in 2018 identified an urgent need to tackle racial inequalities in mental health; inequalities that impact both the experience of living with a mental health condition and the quality of care that patients receive. This disparity is being felt sharply right now – data collected by the Fawcett Society in June found that Black, Asian and minority ethnic (BAME) women are suffering greater psychological consequences as a result of the pandemic, with worries about poverty, debt and unemployment playing a key role.
Even in ‘normal’ times, women of colour in the UK struggle disproportionately with mental health issues – with exposure to racism, among other factors, putting Black women at a greater risk of being diagnosed with a common mental health problem.
Yet data suggests that your ethnicity also informs both your chances of receiving mental health treatment and the outcome of any treatment you do receive. Two years on from the 2018 review that called for change, is therapy still failing women of colour?
For Elizabeth Ayoola, a 31-year-old content writer and entrepreneur from London, the issue began long before she set foot in the therapy room. ‘My experience of growing up as a Black woman was being taught not to air your dirty laundry in public as it brings shame on you and your family. If you were going through something, you were expected to pray and have faith, and that was how it would go away,’ she explains. She thought therapy was for other people, and didn’t recognise her symptoms as depression until they were severe.
After a suicide attempt in 2016, she was offered antidepressants, but she feared they would make her feel numb. It wasn’t until last year, when she was so concerned for her mental health that she worried she would no longer be able to care for her one-year-old son, that she spoke to her GP about talking therapy.
‘It was a last resort,’ she admits. ‘I’d tried everything to no avail – religion, blind optimism, positive thinking...’ She was referred for talking therapy over the phone. The sessions focused on practical ways she could lift her mood; after two, she started leaving the house more often, and after five she was discharged.
She went on to pay for private psychotherapy sessions – first weekly, now fortnightly – which are helping her to tackle the root causes of her depression.
‘I wish I’d got help years ago,’ she adds. ‘If I’d perceived therapy as a safe space for healing, as opposed to a place for someone to listen to my business and judge me, I may have been more open to it. It would have saved me from making many poor and self-sabotaging decisions that I’m having to heal from now.’
The stigma Elizabeth describes isn’t uncommon in some communities, and researchers believe it could explain why white people are more likely to be receiving treatment for a mental or emotional problem.
One 2018 study of 30 Bangladeshi patients using a mental health service in East London found that, though they’d been diagnosed with a variety of problems between them, such as schizophrenia and bipolar disorder, their family members often felt the problem was actually possession by ‘jinns’ or supernatural spirits.
Another study exploring the experiences of Black, Asian and minority ethnic communities in south-east England identified a need for increased mental health literacy, as well as practical support to combat stigma.
But a misunderstanding of what therapy could do for her wasn’t the only thing that held Elizabeth back from getting the help she needed. ‘I thought it was overpriced, and the cost deters many Black women,’ she says. ‘Several I’ve personally suggested try therapy say they can’t afford it, and waiting lists for discounted or free sessions are too long.’
A decade of austerity saw drastic cuts to NHS mental health services, with long waiting times in some areas driving more people to seek private appointments, incurring costs of up to £100 per session. This puts women of colour at a disadvantage, says Lorraine Green, a counsellor and psychotherapist who runs her own East London practice, Therapy In Action. ‘With waiting lists as long as they are, there’s a financial commitment to seeking private therapy that hinders women of colour.’
White British workers earn, on average, 3.8% more than ethnic minorities, with the earnings gap widening to 20% between white workers and those from Bangladeshi households. Household earnings for Black, Asian and minority ethnic people have also fallen from an average of £441 a week to £404 over the course of the pandemic. And among people from ethnic minorities who had their hours cut in April, 20% lost their jobs outright.
For women of colour who do manage to get in front of a therapist, their experience of therapy may not be as positive as it is for white women. Halima’s frustration lay in the unconscious bias that informed the way her therapist related to her; a sense that her practitioner’s gaps in knowledge were plugged with generalised assumptions about her race and religion.
Such stereotyping runs counter to the Ethical Framework for the Counselling Professions, which describes how prejudice exists at both conscious and unconscious levels and includes ‘reacting against or being insensitive towards someone’s cultural values and beliefs’. But the overwhelming message from the women who WH spoke to for this piece is that it does happen.
This isn’t just about bias, but about who you feel comfortable opening up to, says Magda Kiros, a 33-year-old from South London of British-Eritrean heritage. She speaks fondly of the 20-something white counsellor she had eight sessions of CBT with in 2018, after being referred to talking therapy by her GP following the birth of her son. She was feeling overwhelmed and anxious about returning to work, but she was also struggling with racial trauma – an issue she didn’t feel comfortable discussing with a white man.
Two years on, the amplification of the Black Lives Matter movement has left her feeling like she’s ‘had a wound exposed’ and she’s wondering if things could have been different. ‘He was great, and in many ways he helped me, but it wasn’t a space where I felt like I could say what I really needed to say. Partly because some of my anxiety stems from being “other-ed”. It wasn’t that he was a man; I just didn’t want to have to explain myself again to somebody. Even in the explaining, that’s where the trauma lies.’
While research suggests that the ethnicity of a therapist is not a predictor of quality of care, it can play an important role in the way therapists relate to – and treat – their clients.
‘Black and brown women experience things living in this country that a white therapist would simply not be able to relate to,’ she says, referring to the microaggressions that women of colour experience daily, as well as the mental toll of systemic racism.
‘With Black lives being lost due to police brutality, I get the sense that my female Black clients are exhausted,’ says Green. ‘They’re reflecting on their lives and questioning if they’ve compromised too much. There’s a sense of reclaiming one’s Blackness that may be difficult to comprehend if you’re seeing a white therapist.’
Beyond the impact of living in a racialised society are specific pressures that add up to a different lived experience, adds Magda. ‘There are cultural pressures that people from ethnic minority communities feel more, I’d say, than from a white British background, be that who you have to marry, classism or what you should study. And given that a lot of people’s families have come from abroad and made sacrifices that leave children feeling indebted to their parents, there’s a pressure to do better than the last generation.’
Halima and Magda believe their experiences of therapy would have been different if they’d been able to speak to a mental health professional who shared their ethnicity. And while Elizabeth found her white therapist to be ‘incredible’ and ‘non-judgemental’, she plans to transition to a Black therapist to discuss some race-specific topics.
With the current levels of Black representation in psychotherapy and counselling, that could prove difficult. Around 86% of members of the British Association for Counselling and Psychotherapy (BACP) – the leading professional body for UK counsellors and psychotherapists – are white, with just 3% coming from a Black, African or Caribbean background, 2% identifying as Asian or Asian British and 2% having mixed or multiple ethnic groups (the rest preferring not to specify), according to the 2019 membership survey.
As well as recruiting more Black and Asian counsellors and psychotherapists, addressing diversity in the training curriculum will help mental health professionals better relate to patients of all ethnicities, says Eugene Ellis, director at the Black, African and Asian Therapy Network (BAATN). ‘This isn’t just about Black patients being able to see a Black therapist, but about having Black, white, Arab and Asian therapists do the work across a variety of heritages and work through these issues,’ he explains.
He founded BAATN with the goal of helping patients to find BAME therapists, and the organisation has since evolved to become a professional hub for therapists of colour, including mentoring schemes designed to help therapists speak out about their racialised experiences during training.
‘We can’t just have a therapeutic curriculum that works towards the entire population – therapists need to be trained to understand the specific issues that affect Black and brown lives,’ he adds.
Multiple studies have linked the cultural competency of mental health practitioners – their ability to understand, empathise and communicate across cultures – with the quality of care that clients receive in mental health treatment. And studies on cross-racial therapy have found that while matching therapists and clients by race wasn’t a predictor of client satisfaction, the cultural competency of the therapist was.
When WH contacted the BACP, a spokesperson told us that there’s nothing specifically about race and diversity in the core curriculum that courses need to follow in order to be accredited by the BACP. But it’s exploring how ‘diversity could be further embedded in training courses and updating [its] resources and good practice guidance for members’.
Halima believes that if she were to seek therapy again, it would need to be with a Black Muslim woman; for Elizabeth, changes need to be made in education around what therapy is, and what it isn’t, while Magda wants women to feel empowered to do what she couldn’t two years ago: ask for what they need. All would like to see therapists of all ethnicities trained to have more culturally sensitive conversations with their clients. But, adds Ellis, a more inclusive therapeutic framework will only be worth it if people of colour are able to access it – meaning sustained funding of mental health services is essential.
There’s no quick fix solution to this. But talking helps, in more ways than one.
How to access inclusive, effective talking therapy
Where should I look for a therapist?
Find a therapist via an official body, such as the Counselling Directory or the BACP. As well as their qualifications and background, you’ll usually find a photo and a short bio. Do they look and sound like someone you could open up to? Be led by your gut feeling.
I would prefer a Black or Asian therapist — how can I ask for one?
If you’re being referred through the NHS, raise your preferences with your doctor. However, you’ll have more choice if you go private. Use the ‘Find a therapist’ tool on the BAATN website.
To learn more about Black and Asian experiences of therapy, listen to podcasts like Therapy for Black Girls or Stories Of Stigma: South Asian Mental Health.
Can I talk to my white therapist about race?
Absolutely. But, cautions (white) therapist Claire Goodwin-Fee, it’s crucial that you both acknowledge the limits of their understanding.
‘I tell my clients that I can listen, but that I probably can’t connect because I don’t know what it’s like to be a Black or Asian woman.’
How can I find affordable therapy?
Local voluntary organisations may offer free or low-cost therapy. Try Black Minds Matter, Mental Health Matters, Anxiety UK, Turning Point, Mind and Rethink Mental Illness. Also, ask your HR department about an employee assistance programme.
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