‘I want a provider who looks like me’: Why seeing a Black therapist matters to Linn County residents

It was 2020, and Tamara Marcus needed a therapist.

Marcus was a Ph.D. student at the University of New Hampshire when they returned to Cedar Rapids to finish their degree remotely. The transition home was jarring. Suddenly, Marcus was no longer living independently and traveling for research, but cut off from their support network, without a car and living with their parents.

So Marcus, who uses both they/them and she/her pronouns, decided to try therapy. She started with BetterHelp, a company that digitally connects therapists and clients. When the service gave them the option to specify the demographics of the therapist they wanted, Marcus, who describes herself as a Black woman, asked to see a woman of color. They were matched with a white woman. When that therapist didn’t work out, Marcus tried again.

“I was like, I really do want a person of color, and then they matched me with another white woman,” Marcus said. “I tried it with the second person. And again, it wasn’t a good fit. And so eventually I was like, OK, that’s enough for me for this pathway.”

Finding the right mental health professional can be tough for anyone. But for Black people seeking help, finding someone who understands them creates an additional hurdle. A report from Linn County Public Health found a lack of culturally informed care was a key issue for most Black and African American respondents. Working with a Black mental health professional can help Black clients feel heard, but finding one is a challenge of its own.

What is culturally informed care?

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When a 2020 report found health outcomes in Linn County differ across race and ethnicity, Linn County Public Health’s community health program manager, Anne Harris Carter, wanted to dig deeper.

“There's a lot of stuff happening beneath the aggregate,” she said. “If we're not disaggregating things, if we're not looking at data by population group or understanding experiences, we're not doing our job and we're not going to come up with solutions that are meaningful.”

In response, Harris Carter assembled a workgroup with local health care groups — Mercy Medical Center, UnityPoint Health — St. Luke’s and Eastern Iowa Health Center — and community volunteers to investigate where the disparities appear in Linn County. The group quickly settled on mental health as a focus topic and launched a research project that concluded earlier this year. Marcus served as the initiative’s project manager through her company, Empowered Solutions Collective.

Part of the project involved a community survey asking respondents to identify the top three barriers to getting mental health care in their area. The barrier most frequently cited by Black and African American respondents was a lack of culturally informed care, with 78 percent ranking it as a major obstacle. By contrast, only 20 percent of all respondents chose it as one of their top three. No other barrier was chosen as unanimously by any other group.

Culturally informed care isn’t a defined clinical term and doesn’t apply to any specific group. According to Harris-Carter, it’s a practice akin to humility.

“It means that, as a provider, I am knowledgeable to a point but continually learning about cultures that are new or unfamiliar to me, and not presuming that my culture must be the dominant way of doing things,” she said.

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Marcus has a slightly different take.

“Culturally informed care, in my opinion, is when you have a provider who just gets it,” they said.

To explain, Marcus compared finding a culturally competent therapist to finding a trustworthy source of farming advice. If someone from Cedar Rapids who never planted so much as a tomato on their patio were to drive out to Tipton and tell a farmer there how to grow corn, it’d be a hard sell.

“You’re being given advice from someone who doesn’t share these really important pieces … so how likely are you going to be to take that advice?” they asked.

That Tipton farmer would have a lot to explain to the city-dwelling advice-giver: how long their family has been growing corn, the different crop management systems they use, how they plan for seasonal variations and so on.

“You have to spend all of that time and effort and energy getting that person up to the same speed before you can actually start the work,” Marcus said.

On the other hand, they said, if another farmer from Lone Tree were to visit Tipton, it would be much easier to have a productive conversation. Instead of taking the time to lay a foundation to ensure basic understanding, the two farmers could jump right into trading knowledge.

Why do Black clients want a therapist who looks like them?

A therapist doesn’t have to be Black to understand and empathize with a Black client’s experience. But it can help ease clients’ fears about how their provider will treat them.

“The most common thing that we hear is, I want to see a provider who looks like me,” Harris-Carter said. “We live in Cedar Rapids … so that can be hard to do.”

She described someone who participated in one of the research group’s listening sessions who was hesitant to seek mental health treatment for fear of being judged. They said they felt like they had to wear certain clothes to avoid being stereotyped, and they worried their provider would make assumptions about them based on their family structure.

That participant’s decision to dress differently is tied to a skill called code-switching that some marginalized groups use. Some Black people can intentionally change the way they speak, dress and present themselves to fit in somewhere that’s less tolerant of the way they might normally act.

Larry Johnson, a licensed therapist in Cedar Rapids and a Black man, said code-switching is a survival skill. Although it can help people be taken seriously, it can be draining to think so much about how you come across. It’s also not a skill that’s conducive to therapy, which requires clients to be vulnerable.

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“They might not feel comfortable being themselves for fear that someone won’t understand them,” Johnson said. “The implications are significant, because I think misdiagnosis and cultural misunderstandings are linked.”

The factors that drive mental, behavioral and developmental disorders are complex and not fully understood. Yet ongoing research is identifying relationships between race and accurate mental health diagnoses.

According to the American Psychological Association, Black people with a serious mental illness — as well people who are Hispanic, Asian or Indigenous — are more likely to be over-diagnosed with schizophrenia and given higher doses of anti-psychotic medications. At the same time, these groups are less likely to receive treatment for depression linked to their mental illness. Similarly, other studies indicate racial bias may create disparities in autism diagnoses.

Marcus said she felt immediately more at ease when she started working with her current therapist. Seeing a Black woman felt like a weight was lifted off her, she said.

“I don’t have to spend 30 minutes, 60 minutes, whole session, just like laying the groundwork,” Marcus said. “Now I can actually spend my effort and energy talking about the thing that I really want to go deep into.”

Black therapists can help clients work through racist experiences

“For the most part, the Black community never knew therapists — we didn’t know it was available for us,” said Ray Coleman. “We never talked to therapists that look like us, for sure, so it’s not for us.”

Coleman, the senior pastor at Mt. Zion Missionary Baptist Church in Cedar Rapids, is passionate about supporting people with their mental health struggles. He said one of the reasons Black people may seek therapy is to deal with the stress of everyday racism.

“I remember when my son started driving, I had to give them rules that are hidden rules,” Coleman said. “As unfortunate as it is for me to tell you, there are a different set of rules for each race.”

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The conversations Black parents have with their children about these hidden rules, especially as they pertain to interacting with law enforcement, are sometimes called “the talk.” Coleman said he told his son to never drive with more than three of his friends in the car to avoid seeming suspicious to the police. Other common advice includes telling Black boys in particular not to play with toy guns or wear hoodies.

But these hidden rules aren’t limited to police encounters. Marcus said they navigate unspoken norms and expectations in their daily life that don’t have life-and-death consequences, but do impact how other people perceive them. They said therapy and meditation helped them discover their boundaries and what they need to be comfortable in their daily life.

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“Especially as a Black woman, often moving in predominantly white spaces, I was moving through the world with this uncertainty and pressure,” they said. “But there’s this layer of trying to then also assess, is this happening because I’m a person of color, or is this happening for some other reason?”

David Thomas, a licensed counselor in Michigan and the director of the Midwest regional chapter of the National Association of Black Counselors, said a benefit Black therapists provide is the ability to directly address clients’ experiences with racism.

A Black provider can “be able to identify it and say you experienced racism, or you experienced a microaggression, or you experienced this without any question about what it is,” Thomas said.

Of course, no therapist is perfect. Thomas said all providers, regardless of race, need to work on countering their personal biases.

There’s also not a hard and fast rule that people should only see therapists who match their race exactly. Marcus said she had a productive relationship with a therapist who was Indian, even though their experiences weren’t completely alike. She said her therapist made a consistent effort to find resources that aligned with her cultural identity and made it clear she was committed to understanding Marcus.

“Even if you don't have those identities, there's ways that you can still be supportive in those spaces,” Marcus said.

Where are all the Black therapists?

Thomas said clients have called him a “unicorn” in reference to the rarity of finding a therapist who is a Black man. Johnson said he gets similar comments.

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“Being a male in the field is already a rarity in and of itself, and then being a male of color is a whole other subset,” Johnson said.

The American Psychological Association estimated 5.49 percent of psychologists in the U.S. were Black or African American in 2023. A report produced by multiple Black mental health professional organizations in 2022 put the national percentage of professional Black counselors at 11 percent.

By contrast, the most recent census data estimates 13.7 percent of the national population is Black.

Johnson said discussions of mental health needs are becoming more socially acceptable, even in groups typically excluded from mental health care. While he sees more people of color interested in seeking therapy, he said the 8-10 years it takes to become a practicing mental health professional creates a lag between the growing need and the people able to fill it.

“Right now and for the foreseeable future, I think that there will be a gap, because the time that it takes to become a clinician is so far back that it can't keep up with the new boom of everyone realizing that this is something that we should all be addressing,” Johnson said.

How is Linn County increasing support for Black residents?

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In light of the need for culturally informed mental health support the report identified, Carter Harris said Linn County Public Health plans to implement Problem Management Plus (PM+) support groups. Developed by the World Health Organization, PM+ is an evidence-backed social support system for anxiety, depression and stress.

In PM+, trained peer leaders teach a group coping skills like breathing techniques and identifying social supports. Peer leaders don’t need to be mental health professionals, but they are supervised by one. Although PM+ isn’t therapy, it can help people learn strategies to strengthen their mental health by working with someone they trust.

Carter Harris said the county currently anticipates piloting three groups to start, each with a focus on a specific population. Coleman is slated to host a group centered on Black participants at Mt. Zion.

“One of the things I would like to see is the church become a safe place when we can’t talk,” Coleman said. “I think [hosting a PM+ group] will help out. Not only just a safe place, but a place to even start this journey.”

If someone has the time and resources, however, Marcus said they recommend trying therapy with a provider whose lived experience mirror yours.

“Having a therapist that has some of those shared identities can be so impactful. And if they don't, having a therapist that has those cultural competencies is essential,” they said.

Marcus said therapy is a different experience from talking with friends or family members — you get a third-party perspective that can identify things you or the people around you might have missed. The stakes are low, too, they said.

“If you don't think that you'll have any benefit from therapy, just try it, go once. You'll waste an hour,” Marcus said. “I'm sure we can each think of something in our day where we waste more than an hour. So why not waste it doing something like that?

Comments: fern.alling@thegazette.com