By Heather Kugelmass, Ph.D. This article is part of a GAINS Center series on promoting race equity in behavioral health and justice outcomes. Read Part 1 here.
Tyrone Booker was experiencing symptoms of depression and anxiety. Overcoming inhibitions to see a psychotherapist, he left voicemail messages for 80 therapists in his city who were in his health insurance plan’s network, asking for an appointment on any weekday evening. Twenty-five called him back. Five said they had some availability. Only 1 of the 80 offered him an appointment on a weekday evening.
Tyrone is not a real person, but the therapists he called didn’t know that. A voice actor recorded his message, which was played back onto therapists’ after-hours voicemail as part of a social science experiment (Kugelmass, 2016). Each of the 320 unsuspecting therapists received voice messages from one black and one white help-seeker, in random order, spaced one month apart. The fictitious callers were middle or lower class, male or female, black or white. Race and social class were signaled through the caller’s name, accent, and speech patterns. Variations in vocabulary and grammar further emphasized the class cues.
Gatekeeper bias as a barrier
There are many barriers to receipt of care. For black Americans, much of the research emphasis has been on their personal barriers, often attitudinal or financial. The experiment described starts with a person who wants psychotherapy and who has adequate insurance coverage for it. In so doing, it instigates a move away from a focus on why black Americans “delay” or “neglect to” pursue mental health care and toward a focus on how therapists’ behaviors can obstruct access to that care.
Psychotherapists are typically perceived as personally egalitarian and professionally committed to a code of ethics. Nevertheless, research demonstrates that they are not immune to the racial stereotypes pervasive in American culture. This is of critical concern because providers in private practice, especially those with solo practices, have ample opportunity to make decisions about access that are consistent with their biases. The question of how professional discretion contributes to racial disparities has long been of interest to those studying the criminal justice system. For example, considerable attention has been devoted to disparities arising from the discretion of police officers, prosecutors, and judges. Yet, it has not received significant empirical attention in the field of behavioral health.
Some research suggests that therapists prefer clients who are intelligent, verbally communicative, college educated, culturally sophisticated, introspective, motivated, and competent (Howard and Orlinsky, 1972; Link and Milcarek, 1980; Schofield, 1964; Tryon, 1986). Stereotypes of black Americans as having low intelligence, lack of verbal clarity, mistrust, high hostility, lack of educational and employment potential, or reluctance to comply with treatment recommendations could lead providers to avoid these help-seekers (Abreu, 1999; Dovidio et al. 2008; Jones, 1977; Rosenthal and Berven, 1999; van Ryn and Burke, 2000). Related stereotypes of working class and lower class Americans could make them similarly undesirable to therapists.
“Bobby,” a working class help-seeker and Tyrone’s white counterpart, didn’t fare significantly better than Tyrone. However, the middle class white help-seekers in the experiment were strongly preferred over their black counterparts. Within the middle class, racial disparities were particularly pronounced among men: “Jamal” received a 13 percent positive response rate (for any appointment), compared to “William’s” 28 percent.
Therapists’ preference for white over black men was larger than the racial disparity for female help-seekers, which may be attributable to gender-specific stereotypes. “African American men are stereotypically perceived as violent—more so than Caucasian men,” says Aaron Gottlieb, an assistant professor at the Jane Addams College of Social Work at the University of Illinois at Chicago. “These stereotypes are reinforced by misinformation, a failure to consider structural disadvantage, media portrayals, and fear mongering by politicians.”
Are therapists racist?
Does this mean therapists are racist? The extent of discrimination likely varies by context. A study forthcoming in Society and Mental Health examined the responses of a large sample of therapists nationwide to emails sent by fictitious help-seekers through PsychologyToday.com’s directory. Although racial disparities were observed under some conditions, access was better for black help-seekers than in the phone experiment—both in terms of the odds of a positive response and the odds relative to white help-seekers.
Lance Smith, an associate professor of counseling at The University of Vermont, suggests asking a more productive question: “The question for all health care providers and policymakers is not, ‘Am I racist?’ but, ‘What components of racism operate within me without my awareness?’” He adds, “The majority of health care providers and health care policy makers are beneficent, well-intended people who have had white supremacy downloaded into their software without their permission, myself included.”
What can be done to counter the biases that can lead to discriminatory behavior? “Cultural competence training as currently implemented may be insufficient for significantly reducing racial bias,” notes Richard Shin, an associate professor of counseling psychology at the University of Maryland. Shin recommends that we look to the work of social psychologist Patricia Devine, a pioneer in the field of bias reduction, who developed a multifaceted intervention for reducing unintentional racial bias. Devine’s approach, which has achieved longer-lasting effects than other interventions, involves awareness of personal biases, motivation to change, and implementation of strategies to replace them.
Racial disparities in access to therapy exemplify the deeply entrenched inequalities in American society. Mental health care policies, preferences, and practices are inextricably tied to Americans’ positions within social structures—positions that may be reproduced through the behavior of therapists. “We as mental health professionals haven’t focused the lens of scrutiny on ourselves,” says Monnica Williams, a licensed psychologist and associate professor at the University of Connecticut. Comprehensive scrutiny will involve both more empirical research and more self-awareness. But self-shaming needn’t be part of the solution, says Smith, who suggests instead asking oneself: “How are [components of racism within me] negatively impacting the people I’m trying to serve?” and “What must I do to interrupt both individual and systemic racism in order to restore the harm that has been done?”
Abreu, José M. 1999. “Conscious and Nonconscious African American Stereotypes: Impact on First Impression and Diagnostic Ratings by Therapists.” Journal of Consulting and Clinical Psychology 67(3):387–93.
Dovidio, John F. et al. 2008. “Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care.” Social Science & Medicine 67(3):478–86.
Howard, Kenneth I. and David E. Orlinsky. 1972. “Psychotherapeutic Processes.” Annual Review of Psychology 23(1):615–668.
Jones, Alison. 1977. “Dimensions of the Relationship between the Black Client and the White Therapist.” American Psychologist 32(10):850–55.
Kugelmass, Heather. 2016. “‘Sorry, I’m Not Accepting New Patients’: An Audit Study of Access to Mental Health Care.” Journal of Health and Social Behavior 57(2):168–83.
Kugelmass, Heather. Forthcoming. “‘Just the Type with Whom I like to Work’: Two Correspondence Field Experiments in an Online Mental Health Care Market.” Society and Mental Health.
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Schofield, William. 1964. Psychotherapy: The Purchase of Friendship. Englewood Cliffs, NJ: Prentice-Hall, Inc.
Tryon, Georgiana Shick. 1986. “Client and Counselor Characteristics and Engagement in Counseling.” Journal of Counseling Psychology 33(4):471–74.
van Ryn, Michelle and Jane Burke. 2000. “The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients.” Social Science & Medicine 50(6):813–28.