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Another Facet of Racism and Classism in Health Care


Sorry for the delay in the riveting conclusion of the Replication in Psychology series.  I miscalculated days before my vacation swung into higher gear and wound up traveling for a bit.  So conclusion soon, but first I wanted to link to this report on an audit study that finds something shameful, though I guess not surprising: it’s a lot easier for white people and middle class people to get concrete offers of appointments for psychotherapy than black people and working class people.

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.

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As you can see, the way racism seems to primarily influencing therapists in their treatment of prospective clients who are marked as middle-class (although whether they perceive prospective black clients as middle-class is another question).  Prospective clients marked as working class were equally unlikely to get an appointment offer. 

Heather Kuglemass, the author of the study, posits a number of possible causes, including biases toward blacks as antagonistic, toward working class people as lazy.  Another possibility is that therapists have in-group preferences.  Most therapists are white and middle class and therapy is a close relationship.  And they might explicitly reason that black and working class people are less able to pay (though all callers said they were in-network for the therapist), or that they’re not culturally competent to treat someone different than them.  Therapists in private practice have total discretion about who to take and no one is witnessing their decisions, so there’s not as much incentive to examine and safeguard against bias as there would be if treatment decisions were more public-facing. 

Looking for mental health treatment can be really dispiriting even when you fall into the favored categories (the low overall rate of callbacks gives a flavor of this, though that graph doesn’t include therapists who leave a message with an ambiguous request to call back).  I’m glad I read this article just so, when I work in a setting where I have more discretion, I know to watch myself.  The Atlantic article suggests an app that matches therapist and client might be helpful, the way ride hailing apps strip race and class markers from a person hailing a cab, which simultaneously seems like a good idea, and sort of depressing, in that these narrow technological solutions could make one important thing get better, but are tiny measures in the way race and class inequities permeate every aspect of American life. 

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