Black and working-class individuals are less likely to find therapists who will see them, according to new research
Experts worry that therapist bias could be an important barrier to mental health care for minority and low-income groups
Minorities and lower-income individuals can face numerous challenges in getting treatment for depression and other mental health problems. They may lack insurance or transportation to a therapist’s office; they may experience stigma in their communities around mental illness that prevents them from seeking care.
A new study finds that these groups face yet another barrier to mental health care: Therapists may be less likely to see them.
To study whether therapists had biases, researchers hired actors to record voice messages for 640 therapists in New York. In all the messages, the actors read scripts saying they had been feeling down, had insurance and would like to make an appointment.
The scripts varied the names, vocabulary and grammar to reflect race and class differences. For example, the name Amy Roberts was supposed to indicate that the caller was a white middle-class woman, whereas Latoya Johnson was used for a black middle-class woman. The scripts for working-class individuals used more slang and some grammatical errors.
The researchers waited one week for the therapists to return the calls, which went to a voice mailbox created for the study. The researchers recorded whether the therapists agreed to see the new client and whether they could accommodate the desired time, which was a weekday evening.
Middle-class black women and men were about 30% and 60% less likely, respectively, than their white middle-class counterparts to hear back from a therapist agreeing to see them. Working-class individuals fared even worse: Women and men, regardless of race, were about 70% and 80% less likely, respectively, to get an appointment, compared with white middle-class individuals.
“Psychotherapists are not immune to the same stereotypes that we all have, and I think they could become even more relevant for psychotherapists than for other professions [both medical and nonmedical], because they are embarking on this intimate, potentially long-term relationship with these [clients],” said Heather Kugelmass, a doctoral student in sociology at Princeton University. Kugelmass is the author of the study (PDF), which was published Wednesday in the Journal of Health and Social Behavior.
A large survey in 2015 found that 40% of physicians in the United States had biases about their patients, most commonly because of their emotional problems and weight, but income level and race were also on the list. Research suggests that these biases affect the quality of care that patients receive. Although studies also suggest that biases could prevent primary care doctors from accepting patients, no one had explored the effect of stereotypes on therapists’ willingness to see patients.
The current study found that therapists’ response rate was low in general, with only 44% returning the call. In many cases, the therapist left a message saying he or she did not have availability: Only 15% of inquiries resulted in a therapist offering an appointment time.
Therapists were less likely to call back if the clients sounded black and working-class. Only 34% of black working-class individuals got a call back, compared with 49% of black middle-class and 51% of white middle-class individuals.
“As consumers, or potential consumers, of mental health care, we would like to think that everyone deserves a response,” Kugelmass said.
Overall, 28% of the middle-class white individuals seeking care were offered an appointment, compared with 17% of the middle-class black group and 8% of the working-class white and black groups.
The lack of therapist availability is particularly grim when you think about the hypothetical patients, Kugelmass said. They communicated their insurance coverage, indicated the time they would like to see the therapist and politely asked for a return call, yet few of them received one, and even fewer got an appointment. “[Working-class people] are facing a difficult and probably unexpected obstacle to care,” Kugelmass said.
“The findings of this research are not at all surprising to me,” said Dr. Joseph R. Betancourt, director of the Disparities Solutions Center at Massachusetts General Hospital and Harvard Medical School.
“It completely falls in line with research not only in health care but in other areas,” said Betancourt, who was not involved in the current study. Research has found racial discrimination in many sectors of the economy, including in housing rentals and auto lenders.
Part of the reason for the discrimination could be because the vast majority of mental health care providers are white and “might feel less of an affinity or ability to care for somebody who is different,” Betancourt said. Only 5% to 7% of mental health care providers in the United States are racial or ethnic minorities, he added.
“Diversifying the community of mental health care providers would go a long way,” Betancourt said. Other steps that he said can and should be taken are to teach therapists-in-training about their stereotypes in graduate school and to audit therapists routinely, as the current study did, to make them aware if they are excluding certain groups from their care.
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“I bet if you asked any individual [in the study] if they limited access, they would say ‘absolutely not, I see everybody,’ ” Betancourt said. Making people aware “would start to move us in the right direction,” he added.
Even though the current study included only therapists in New York, the trend would probably be the same anywhere in the United States, Betancourt said. “You have so many studies that find a trend that it is hard to argue it is just a phenomenon of where you are,” Betancourt said.