Good Luck Getting a Therapist If You're Black or Working Class
When it comes to finding a therapist, it pays to be well-off and white.
That’s the sobering finding of "Sorry, I'm Not Accepting New Patients": An Audit Study of Access to Mental Health Care, a study published in the June issue of the Journal of Health and Social Behavior. The research, led by Heather Kugelmass, a sociology graduate student at Princeton University, found that therapists are less likely to call back and offer an appointment to people who sound like they’re black or from a lower-income background.
“Although we expected to see evidence of racial and class-based discrimination, the magnitude of discrimination against working-class therapy seekers, in particular, was considerably larger than expected,” Kugelmass wrote in an email to TakePart.
For the study, Kugelmass randomly selected 320 New York City–based therapists listed in Empire Blue Cross Blue Shield’s HMO directory. She focused on therapists with Ph.D.s or Psy.D.s, “in part because they are overrepresented in solo private practice among mental health care providers. They have ample opportunity to make decisions about access that are consistent with their biases because they retain exclusive discretion over the provision of their services,” wrote Kugelmass.
Kugelmass then hired an equal number of male and female voice actors to call the therapists’ offices and leave voicemails requesting weekday appointments. Some actors pretended to be black therapy seekers by using traditional black-sounding names and using a script Kugelmass created using research on African American Vernacular English and black-accented Standard American English. Other actors pretended to be working-class therapy seekers by adopting thick New York City accents and modifying their vocabulary and grammar.
Kugelmass found that nearly 30 percent of therapy seekers who sounded like they came from middle-class white backgrounds were offered appointments, which isn’t exactly a stellar overall response rate. But middle-class-sounding black women received appointment offers 21 percent of the time, while black men who sounded middle class received appointment offers 13 percent of the time. Therapy seekers of both races and genders who sounded like they were from a working-class background received appointment offers less than 10 percent of the time.
Dr. Lynn Bufka, the American Psychological Association's associate executive director for practice research and policy, acknowledged that the findings of the study are troubling.
"Psychologists, just like any other health care provider, are human and subject to biases. We hope that as professionals we have some awareness and sensitivity to the potential for bias and make efforts to overcome that but we are not perfect, we are human,” Bufka wrote in an email to TakePart.
She also expressed concerns about Kugelmass’ research methodology because the study “only looked at the rates with which patients were offered an appointment.”
“Many therapists schedule a phone consultation with a potential client prior to scheduling an appointment and will not offer an appointment time without first having that conversation," Bufka wrote. "This is primarily to make sure that they have the right skills and experience to treat that individual and for the client to find out if they are the right fit. He or she may want to understand how severe the problem might be and, if necessary, refer to more intensive treatment rather than outpatient psychotherapy.”
Bufka pointed out that there is a “significant difference between the working class and middle class scripts in terms of how directive they were.” This matters “because psychologists are very careful leaving voicemails when it’s not clear if the mailbox is private or if the client or potential client hasn’t made it clear that it’s okay to leave personal details. If it’s a shared phone, this may be breaching confidentiality,” wrote Bufka.
Phillipe Copeland, a professor at the Boston University School of Social Work, wrote in an email to TakePart that Kuglemass’ research is “an important contribution to research on health inequities related to racism and classism, particularly when it comes to barriers to access.” But for Copeland, limiting the research to “Ph.D.-level psychologists leaves out one of the largest providers of behavior health care, which is social workers.”
“I'm not implying that social workers are less racist or classist than psychologists but the study design doesn't allow for comparison and leaves out a significant group of providers,” wrote Copeland. But he is “curious about the numbers of low income people of color seeking behavioral health from private practitioners vs. those in more public settings such as community health centers. Basically does this disparity really have a big impact on the people in question or are most of them not seeking therapy from the folks represented in this study anyway?”
In addition to having to overcome typical fears about seeking assistance, because of the stereotype that black people don’t go to therapy, it can sometimes be tough for folks of African descent to reach out for help. Along with a cultural mistrust of the medical profession, thanks to the Tuskegee syphilis experiment—and a lack of access to affordable, high-quality health care—folks might feel like they should stick to praying with a pastor or talking with an auntie, just like their forebears did for generations.
Given that roughly one-third of black Americans live in poverty, Kuglemass’ research has dire implications for the mental health of black men who come from lower-income backgrounds.
“Consider the voice message portraying a black working class man. This message represents an individual who overcame the stigma associated with seeking care, had mental health coverage for therapy, consulted his insurance directory, and selected PhDs or PsyDs in New York City,” Kugelmass wrote to TakePart. “This hypothetical man left messages for 80 therapists. He said that he wanted help with symptoms that are associated with depression or anxiety, communicated his insurance plan, indicated that he’d prefer to see the therapist on a weekday evening, and politely asked for a return call. Only one of those 80 ultimately offered him a weekday evening appointment.”
Ironically, "Becoming an Adult in the Face of Racism," the cover story in the June issue of the APA magazine Monitor on Psychology, notes that "racial discrimination is related to depression, suicide, violence, stress disorders, and maladaptive coping strategies, such as substance abuse, among African Americans."
To counter bias, wrote Bufka, the APA provides “materials and guidelines for its members on working with individuals of different backgrounds and trying to identify and overcome one’s own deficits in skills or competence.” In addition, many “jurisdictions require documented training in ethics, multicultural competence, diversity or other related areas to remain licensed.”
Kugelmass pointed out that, thanks to the Affordable Care Act, more working-class people now have access to health insurance, which should make it easier to find a therapist. "There are millions of people who now should have access to the private mental health care market and who would, presumably, prefer to seek care there than at community health centers,” she wrote.
To Copeland's point, Kugelmass says she is working on new research on other kinds of mental health providers, to see whether “working-class therapy seekers would receive more positive responses from social workers, who may be more willing to work with disadvantaged populations."
“Awareness is a first step," wrote Kugelmass. "I hope this study generates discussion among clinicians, psychology training programs, professional associations and insurers."