Need Therapy? That'll Be Tough If You're Not White or Middle Class

For many Americans, the hurdles to accessing mental health services are numerous and overwhelming. The majority of counties in the country, some 55 percent, “have no practicing psychiatrists, psychologists, or social workers,” according to the U.S. Department of Health and Human services. For decades, states have been slashing mental health care budgets, with recessionary cuts going particularly deep, reaching an estimated $5 billion in reductions in the three years between 2009 and 2012. Even as legislators have ransacked mental health budgets, they have grown boundlessly generous toward prisons, increasing spending by an estimated 140 percent between 1986 and 2013. Consequently, a 2014 study by the Treatment Advocacy Center found that in 44 states and the District of Columbia, more mentally ill people are housed in jails than psychiatric hospitals.

Earlier this year, President Obama introduced a 2017 budget proposal that includes $500 million in mental health care spending, a challenge to congressional Republicans who insist that guns don’t kill people, mentally ill people kill people. Putting aside the unlikelihood that GOP lawmakers will, in the president’s words, put their money where their mouths are, even under the best budgetary circumstances, mental health seekers will still face barriers to accessing treatment. Among these are race and class biases, which a new study finds can impact mental health service options in ways that are troubling yet unsurprising.  

Princeton sociologist Heather Kugelmass had voice actors call 320 randomly selected New York City psychologists listed as network providers by Empire Blue Cross Blue Shield’s HMO plan. Kugelmass looked at psychologists in particular—versus say, social workers and other therapists working outside of “solo private practice”—because a significant proportion are independent operators, meaning they “have a lot of latitude to make decisions,” including discretion in client selection. In each case, the psychotherapists were left voicemail messages requesting weekday evening appointments. Using speech markers of class and race—an imprecise science, granted, but one Kugelmass based in research on dialogue and accent patterns—the study’s therapy seekers presented themselves as a member of one of four groups: black middle class, black working class, white middle class or white working class. Each therapist received two calls, one from a supposed black caller and another from a white caller, each representing different classes. All of the voice actors, who were equally divided by gender, mentioned they were members of the psychologist’s insurance network and stated they were experiencing feelings of depression.

Chances of getting a call back weren’t particularly great in general; just 44 percent of voice messages garnered any response at all. (Kugelmass lamented this fact in an interview with Reuters, noting that “everyone deserves a response.”) In the remaining cases, probability of a call-back correlated with potential patients’ perceived whiteness and wealth. Twenty-eight percent of therapists returned calls and offered an appointment to those who “presented” as middle-class and white, but just 17 percent of middle-class black callers received a return call. Therapists were also more likely to offer the requested time slot of weekday evenings to middle-class whites. Across race, working-class callers were pretty much ignored; a mere 8 percent were offered appointments.

Kugelmass notes that gender also had a significant impact. Middle-class black women received appointment offers from 21 percent of therapists, compared to just 13 percent for middle-class black men. But no one fared quite as well as the middle-class white female character. Therapists “prioritized” her “for coveted weekday evening appointments”—she was offered the sought-after slot by 20 percent of 80 psychologists. On the other end of the spectrum, the black working-class man had just one therapist make the same offer after placing 80 calls. As the Atlantic notes, were Kugelmass’ study “to play out in the real world, an identifiably black, working-class man would have to call 80 therapists before he was offered a weekday evening appointment. A middle-class white woman would only have to call five.”

"Although I expected to find racial and class-based disparities, the magnitude of the discrimination working-class therapy seekers faced exceeded my grimmest expectations,” Kugelmass stated in a press release announcing the study findings. “The fact that this study uncovers discrimination in the private mental health care marketplace is consistent with previous audit studies that have revealed discrimination in other marketplaces, such as housing and employment.”                  

Kugelmass’ findings hold larger implications about the many factors that prevent people from getting mental health care in this country. Health insurance for all would help level the playing field in some ways, but biases at the practitioner level can be enough to keep doors to mental health treatment firmly closed.

"It is striking that discrimination toward black and working-class therapy seekers occurred even though all therapy seekers had the same health insurance and were contacting in-network providers," Kugelmass added. “This evidence points to bias rather than financial considerations. It is possible that if insurance coverage had not been held constant, inferences based on racial and class stereotypes would have augmented discrimination even beyond that which was observed."

In his 1964 book Psychotherapy: The Purchase of Friendship, University of Minnesota professor William Schofield presented survey findings indicating many psychotherapists envisioned the ideal therapy patient as “youthful, attractive, verbal, intelligent and successful." Kugelmass suggests these feelings still persist among many in the overwhelmingly white, highly educated and socioeconomically advantaged field of psychology. For potential patients who are not white and wealthy, racism and classism conspire to place mental health services far out of reach. Many practitioners may be unwilling to “embark on an intimate, long-term relationship with someone they feel they can’t relate to,” Kugelmass suggests.

There’s also the fact that therapy is almost always pricey. The Atlantic points to a survey from the American Psychological Association that finds roughly 30 percent of psychologists don’t take insurance at all, leaving all costs up the patient. In cases where clinicians do accept insurance, co-pays differ greatly depending on a number of issues, and many plans—even those not strictly defined as “catastrophic”—have exorbitant deductibles that can require shelling out thousands before the insurance even begins to cover sessions. In New York City, where it’s pretty standard for therapy to run $150 per session and up, the prospect of spending even an hour a week on the proverbial couch, insured or not, is prohibitively expensive for lots of people. Though the voice actors in Kugelmass’ study indicated in their messages that cost wouldn’t be an issue for them, practitioner ideas about class and financial returns likely still held sway.

“Deeply rooted stereotypes associated with the working class could lead to negative reactions to their requests for care,” Kugelmass told Reuters. “Even though all therapy seekers in the study were covered by the same insurance, it is possible that mental health care providers view working-class patients as a financial risk because, for example, they cannot be relied upon to keep appointments or pay insurance co-payments at the time of treatment.”

All of these findings are critically important in a nation where trauma and other mental health issues impact large swaths of the population, disproportionately affecting the poor and people of color. A 2009 World Health Organization found that America leads the world in anxiety disorders, which an estimated 19 percent of the population struggles with. Poverty and depression are often coupled, with one study finding that “31 percent of [poor] Americans say they have at some point been diagnosed with depression.” As I noted in a previous article, “the trauma incurred from issues that disproportionately affect African Americans, from poverty to unemployment, can also take a deadly toll” on mental health, with “multiple studies find[ing] that African Americans are “’significantly more likely to report major depression’ than other groups.”

[O]ne group of researchers conclud[ed] that black Americans are “20 percent more likely to report having serious psychological distress than” whites. In addition to the everyday difficulties that impact white lives, blacks must deal with “race-based trauma,” the result of both personal confrontations with racism and secondhand experiences, such as those that arise from viewing repeated coverage of racist violence, which has been linked with post-traumatic stress disorder.

Heather Kugelmass’ study is among the first to investigate the connection between clinician bias and mental health access, but it will hopefully provoke more researchers to look into the subject. Larger study samples and broader indicators, beyond measuring call backs and appointment offers, would likely provide greater insight, as would contrasts among different types of providers, as one Boston University School of Social Work professor suggested, speaking with Take Part.  

But even on its own, Kugelmass' study findings are critical to the conversation about mental health. Her report reveals just how deeply race and class privilege, and lack thereof, affect every aspect of our lives, including our psychological well-being, and how every American institution, and the players within it, helps perpetuate white supremacy.

"Unlike employers or real estate agents, psychotherapists have not previously faced empirical scrutiny for potentially discriminatory behavior," Kugelmass said. "This research provides a window into an otherwise private exchange that may subtly perpetuate disadvantage."


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