Around one in four Buncombe County residents reported having more than a week of poor mental health in a month, according to a 2018 report by the county's Health and Human Services Department. Finding and affording a therapist are two barriers for treatment, but historically marginalized communities also face cultural stigma and a lack of providers who share their experiences.
Michelle Álvarez has over 15 years of professional experience as a therapist. She's worked in Asheville a little over a year and wants to create a space where her clients feel comfortable opening up.
"It's just a conversation," said Álvarez on therapy. "It's not like on TV. We're not scary people. It's just talking."
Practicing in Asheville is a change from her previous work in New York City.
"I think the public perception is that Asheville is predominantly white," said Álvarez. "I think we're underestimating how many people of color there are here."
According to the National Alliance on Mental Illness, Black and Latinx people "use mental health services at about one-half the rate" of white people. Álvarez believes that along with access and affordability issues, there is also cultural stigma attached to going to therapy.
"In Hispanic cultures, in Black cultures, you're expected to tough it out," said Álvarez. "Therapy is for crazy people. Why would you go an air your dirty laundry to a stranger? I think some people might see it as a luxury for white people."
While Álvarez serves a variety of clients, she understands why clients of color might feel more comfortable with someone who shares their experiences.
"It's a sort of shorthand and familiarity we share with our clients, not having to explain everything," said Álvarez. "It ends up being more comfortable for the therapist and the client."
Álvarez is one of a handful of Latinx therapists in the area who serves Spanish-speaking clients. One client drives two hours for services.
"That's a lot of pressure on me," said Álvarez. "I have to give them the best service I can."
A lack of mental health professionals of color is not just a problem in Western North Carolina. The American Psychological Association reported that in 2016, around 85 percent of therapists in the United States were white. The report also stated five percent of therapists were Hispanic and four percent of therapists were Black.
For community mental health advocates, connecting people to mental health services is made more challenging by the lack of professionals of color.
Sharon Pitt and her husband, Jim, have worked with Western North Carolina's NAMI chapter for over 20 years. NAMI Western Carolina connects people with mental illness and their families to resources and support groups. Pitt thinks one of the reasons Asheville lacks therapists of color is because the city is transitory.
"One of the problems I think that we have with getting Blacks in the psychiatric profession here in Asheville is that for young people, professionals in general who are Black, Asheville is a pass-through place," said Pitt. "It's just one step on the way. Asheville is really looking for people close to retirement and this is going to be their last stop. That's the kind of people we get and keep."
Pitt and other advocates struggle to find Black practitioners when connecting people to mental health services. Kathey Avery is a registered nurse with the Asheville Buncome County Institute for Parity Achievement. The non-profit organization provides health education and treatment for low income people of color.
Avery goes door-to-door in the county identifying people's health needs and providing them with medical and mental health treatment.
Both she and Pitt could think of two Black practitioners in the area, one at NC Brookhaven Behavioral Health and a private practice psychiatrist.
"That doesn't mean if we dug deep and long we might not find maybe three," said Avery. "But I'm pretty sure on one hand, that's pretty accurate."
Avery also teaches classes on health access and information for the community. When holding a class for Minority Mental Health Month, people shared that they avoided the mental health system because of a lack of trust. They primarily found support in religious communities, but Avery said it's not a perfect system.
"Most of them said that they would go have prayer, and I said, well, how many of you would feel comfortable talking to your pastor about your mental health needs after you had the prayer?" said Avery. "Not a single person in that room raised their hands."
Buncombe County Health and Human Services highlighted mental health as the top issue to address in the county over the next three years.
In the meantime, Avery, Pitt and therapists like Álvarez are helping people find practitioners they can afford and trust. Álvarez said her ultimate goal is helping clients find the right fit.
"I might not be the right therapist for you," said Álvarez. "I'm not the right therapist for everybody, and the beautiful thing about the mental health community in Asheville I feel like is we're not trying to hog all the clients. We refer out."
Álvarez and other professionals are laying the groundwork for a conference in the following year that will provide training for therapists in the area and increase their understanding of these cultural barriers to better serve the county's minority population.