Not White, Not Rich, and Seeking Therapy

Even for those with insurance, getting mental healthcare means fighting through phone tag, payment confusion, and even outright discrimination

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Last year, Decker Ngongang realized he needed to find a good therapist to help him with a lot of little stresses that were piling up.

“I grew up in a single-parent household,” he said. “A lot of the things I wanted to talk about were just childhood-related, but also the stress of being a black man in America.”

He figured it would be similar to getting someone to take a look at a knee injury. Ngongang has good insurance through his work as a consultant for NGOs in Washington. So he opened up his insurance company’s website, typed in “psychologists,” and started calling.

And calling. And calling.

Some of the therapists said they weren’t taking new patients. In some cases, he left a message and never heard back. One said Ngongang would have to wait months for an appointment. In all, he estimates he contacted more than 25 therapists.

As with any individual’s situation, it’s impossible to know exactly why Ngongang found himself stuck without an appointment. Between 30 and 50 percent of psychologists run their own practices, which allows them to largely control their own schedules, client rosters, and insurance networks. About 30 percent appear to accept no insurance at all, according to the American Psychological Association, a trade group for psychologists.

But a new study suggests there might be another problem at play when low-income and black people attempt to schedule psychotherapy appointments: They never make it past the first voicemail. The study, published in the June issue of the Journal of Health and Social Behavior, suggests psychotherapists are more likely to offer appointments to middle-class white people than to middle-class African-Americans or to working-class people of any race.

For the study, Heather Kugelmass, a doctoral student in sociology at Princeton University, selected 320 therapists from the directory of Empire Blue Cross Blue Shield’s HMO plan in New York City. She then had voice actors call them and leave voicemail messages saying they were depressed and anxious. They asked for a weekday evening appointment. She distinguished between different income groups by altering the vocabulary and grammar in the scripts, and she used studies on African-American vernacular and Black-accented English to craft the African-American callers’ scripts. The lower-income white callers spoke in a heavy, New York City accent. All of the callers mentioned they had the insurance that the therapists purportedly accepted.

Then Kugelmass counted the callbacks.

Percentage of calls that elicited any appointment and preferred appointment offers (Journal of Health and Social Behaviors)

She found 28 percent of white, middle-class callers were called back and offered any appointment, compared to just 17 percent of African-American, middle-class callers. Only eight percent of the working-class callers of either race were offered an appointment. When therapists offered appointments in the ideal time slot—weekday evenings—the wealthier, white callers prevailed once again.

Kugelmass also found subtle differences by gender, with the odds largely stacked against black men. If her experiment were 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.

Psychotherapists tend to favor patients falling under the acronym “YAVIS”—young, attractive, verbal, intelligent, and successful, according to other studies. They like “psychologically minded” clients who remind them of themselves. One study found that psychiatrists view black patients as “less articulate, competent, [and] introspective,” Kugelmass wrote. Just 5 percent of psychologists are African-American.

In the minds of many psychologists, Kulgelmass said, a preference for richer clients might combine “with stereotypes of black men as hostile or recalcitrant.” Providers might be reluctant “to embark on an intimate, long-term relationship with someone they feel they can’t relate to.”

It’s hard to know precisely what the therapists in Kugelmass’ study were thinking. For one thing, 31 percent of the callback messages weren’t very clear, saying only something like, “please call me back.”

And it’s hard to purposefully make a person sound poor or black. In the working-class white script, for example, the actor said “hiya doc,” instead of “hello,” and mentioned “on the website I seen your name.” The working-class black script included flourishes that bordered on cartoonish, like “a’ight?” and “my numba.”

Lynn Bufka, a psychologist with the APA, said therapists’ biases certainly might have played a role in the results. But, she added, many psychologists might avoid leaving a detailed message on a prospective patient’s voicemail out of privacy concerns. What’s more, it’s unclear whether all of the therapists actually accepted Blue Cross, she said, since sometimes insurance directories are incorrect.

Still, Bufka understands why people might feel help is out of reach. “For someone who’s looking to access psychotherapy, they have to be persistent,” she said. “That’s unfortunate, because you might not have many emotional resources. Calling someone and not being called back feels like rejection. I would hope that we’re all making a good effort to return phone calls, but it doesn’t always happen.”

Discrimination by therapists compounds the already steep obstacles Americans face in accessing mental health care. There are shortages of mental-health providers even in wealthy areas, and more than half of all counties in the U.S. have no practicing psychiatrists, psychologists, or social workers. In any given year, about one in five Americans has a mental illness, according to the National Alliance on Mental Illness, but nearly 60 percent of those people don’t get services.

Patient advocacy groups have long complained that not enough therapists accept insurance, forcing many of their patients to pay high out-of-pocket rates. (Psychologists’ groups, including the APA, contend that insurance companies’ reimbursement rates are not high enough.)

“If it’s a market where you pretty much have to pay for yourself, the rich are always going to win,” Stanford University psychiatry professor Keith Humphreys told KQED recently.

Ngongang finally did get an appointment, but he realized only after the session that the therapist didn’t accept any insurance. He would have to foot the entire $150 bill himself.

“If you have a good session, you want to go once a week,” he said. “That’s like daycare.”

Alicia Raimundo, a mental-health advocate who now lives in Toronto, said the barriers to access in psychotherapy are especially egregious because many people feel ashamed for needing help in the first place.

When Raimundo was looking for a therapist while living in New York several years ago, she said she used a Westernized version of her last name—Raymond—when contacting therapists online. Her email response rates were higher that way, she said.

Ngongang said there might be a tech solution to psychotherapy’s access problems. For years, he said, taxis wouldn’t stop for him. The rise of Uber, where the hailing process is colorblind, has made it much easier to find a ride. Perhaps a similar app for insurance-accepting psychologists would improve things, he mused.

“Now that we recognize mental health is an important piece of wellness, how do we create infrastructure to support that?” he said. “Right now, it’s a luxury. It’s implied that it’s for a certain class.”