Has Therapy Become “A Hobby of the Rich” (and White)?

Way harsh, Tai, but kind of true

Dr. Melfi

Stanford psychiatry professor Keith Humphreys has some choice words for the students he trained who then went into private practice and refused to take, or treat patients who must rely on, health insurance. According to a write-up in NPR, he believes teaching them was a waste of time.

“A minute I spend training that person is a minute of my life wasted,” Humphreys says. “That very well-trained person should be taking care of very, very troubled people. When they don’t, everyone who needs that care loses out.”

The article traces the history of mental health care payments in the 20th century and the way in which our two-tiered system developed. Of course, when given the option, doctors chase higher cash payments, especially since those often come from white-collar types with relatively simple problems (or, as Humpreys puts it, more scathingly, “people who enjoy the self-exploration of therapy but don’t necessarily have a mental health problem”). The result is that the teeming masses of people who can’t afford to pay several hundred dollars an hour out of pocket, but who really need mental health care, are SOL.

Treating high-functioning professionals in a private office is a lot less stressful than doing rounds on a psychiatric ward in a public hospital.
Especially in affluent places like the San Francisco Bay Area, this creates a divide, a culture of mental health haves and have-nots. Mental health clinicians don’t need to participate in the health care system or take insurance to keep their schedules full — making it harder and harder for people of lower income to find a therapist.
“That’s why you can have a lot of mental health professionals in an area, but still have a shortage of care for people in need,” Humphreys adds. “The person who’s hurt is the person who’s suicidal, maybe they’re horribly addicted to OxyContin or their child is showing signs of bipolar disorder, and they can’t find somebody to take their insurance. It’s unjust.”

As the commenters on the NPR piece point out, this is really a problem of insurance. Even psychiatrists who want to work within the system are often frustrated by byzantine and time-consuming reimbursement policies. And it’s no secret that insurance companies are scaling back coverage at the same time that our workplaces are pushing more and more of the cost onto individuals, so we’re all paying more for less.

Also, the article conflates psychiatry with therapy in a way that’s confusing. As fields, they’re pretty different. I’ve never had trouble finding a mediocre psychiatrist who would take my insurance, but none of those doctors practiced therapy, and thank goodness, because each of them, for whatever reason, had terrible people skills. They prescribe and manage medication and that’s about it.

On the other hand, I’ve never had trouble finding a good therapist, usually a clinical psychologist — so long as I was okay paying out of pocket. I’m currently on hiatus from therapy because, although it’s tremendously useful in helping me manage my anxiety, it’s expensive and not covered by my insurance. Since even 45 minutes once every two weeks is priced like, and feels like, such a luxury, I’m having a hard time justifying the expense to myself right now.

Turns out I’m lucky that I even have the opportunity to consider whether the cost of therapy is worth it, though. An article in Psychology Today from 2013 bluntly stated that the field is rife with discrimination.

And a new study has found that many poorer folks and/or minorities still can’t even get a psychologist to return their calls.

A Princeton sociologist did a study in which she got voice actors to leave messages for psychologists who do ostensibly take insurance — “320 randomly selected New York City psychologists listed as network providers by Empire Blue Cross Blue Shield’s HMO plan” — and found some dispiriting truths about who can get access to help and who can’t.

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.

Basically, these therapists are all waiting for me to call them.

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.”

Can you imagine having the resilience, especially when you’re feeling depressed or anxious, to dial up 80 therapists? Who wouldn’t give up, facing those odds? And even then, you need to find a good personality match, which is by no means a guarantee, as this personal essay in Ebony makes clear.

Seems like the next call these wayward psychologists should get is from an incensed Dr. Keith Humphreys.