Study of returned calls from psychotherapists for requests for first appointments got lots of attention in social media but were claims accurate?
A recent paper reporting results of calls to psychotherapists for a first appointment got lots of attention in social media after a story in The Atlantic made provocative statements about its results.
Some of the claims in the Atlantic article resonated with readers assumptions about how difficult it is to get an appointment
Even for those with insurance, getting mental healthcare means fighting and through phone tag, payment confusion, and even outright discrimination
A lot of the attention to the Atlantic article was due to prominent display of the claim:
Sure, it is plausible that a black working-class man would have a harder time getting an appointment, but it really take 80 to get a first appointment?
The Atlantic article zeroed in the interaction between gender, class, and race that was presented as more complex in the actual report of the study
Among working-class callers, the study showed equal rates of appointment offers between white and black callers; if perceived race were causing class misidentification by therapists, then one would instead expect to see lower appointment offers for black working-class callers. If anything, the true race differences within the middle class may be slightly smaller than observed, and the class differences among blacks may be slightly larger than observed. Ultimately, the sizeable and statistically significant effects support the conclusion that there is a true disadvantage to black middle-class help seekers and all working-class help seekers, relative to middle-class whites.
So maybe class mattered more than race.
The apparent strength of findings might reflect methodological weaknesses of the study and the author’s stereotypes as much as the prejudices of the therapists who were called. The Atlantic article noted:
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.
The Atlantic article acknowledged:
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.”
The Atlantic article drew some strong reactions, like from a psychologist from Australia, where there are different expectations of psychotherapists:
But a Minnesota psychiatrist offered a more sympathetic view of the therapists, noting that insurance companies and managed care share some of the responsibility for the difficulties those in need have in getting a first psychotherapy appointment.
Finally, the Atlantic article provided some relevant statistics
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.
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.
And some good quotes, like:
“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
The original study reintroduced the concept of the YAVIS patient desired by therapists, something I have discussed with respect to psychosocial care of cancer patients. The article said
Research suggests that psychotherapists (hereafter also called “therapists”) favor help seekers with the “YAVIS” attributes: young, attractive, verbal, intelligent, and successful (Tryon 1986). Consistent with the YAVIS hypothesis, Teasdale and Hill (2006) found that therapists prefer “psychologically minded” clients and those who share similar values and attitudes. These effects were independent of the demographic characteristics (including race) of the help seekers, but the results were survey based, so social desirability pressures may have influenced the results. In another study, black patients were rated by psychiatrists as “less psychologically minded” as well as “less articulate, competent, [and] introspective” than otherwise equivalent white patients (Geller 1988:124).
The Atlantic article
The original study
Kugelmass H. “Sorry, I’m Not Accepting New Patients” An Audit Study of Access to Mental Health Care. Journal of Health and Social Behavior. 2016 Jun;57(2):168-83.
Through a phone-based field experiment, I investigated the effect of mental help seekers’ race, class, and gender on the accessibility of psychotherapists. Three hundred and twenty psychotherapists each received voicemail messages from one black middle-class and one white middle-class help seeker, or from one black working-class and one white working-class help seeker, requesting an appointment. The results revealed an otherwise invisible form of discrimination. Middle-class help seekers had appointment offer rates almost three times higher than their working-class counterparts. Race differences emerged only among middle-class help-seekers, with blacks considerably less likely than whites to be offered an appointment. Average appointment offer rates were equivalent across gender, but women were favored over men for appointment offers in their preferred time range.
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