U.S. fails to provide mental health care to those who need it most

At the height of the pandemic in 2020, I decided I wanted to make a major life change: I would leave journalism and become a psychotherapist.

I spent many hours researching the different paths to licensure, and the kinds of jobs you can pursue once you’re a marriage and family therapist, a clinical psychologist or a clinical social worker (the route I ended up going).

I believe that everyone should have access to quality mental health services, so working at a community-based agency seemed like it might be a good fit. But the more I learned about the reality of those jobs, the more demoralized I felt. Even though the work can be highly rewarding, the pay is relatively low, caseloads are high, and burnout is rampant.

It’s this sobering portrait of community-based mental health services that nudges many new clinicians into private practice, where you can make a comfortable living and have control of your own schedule.

One Group Therapy reader is facing this dilemma and sent us this question: “As a clinical psychology graduate student, I am more interested in where we go from here with our mental health services. I am worried that there will be a lack of places for people like me who are interested in helping those less fortunate and working in lower-income communities.”

My first thought when I read this question is that there are actually plenty of mental health jobs for those who would like to work with people in underserved communities. Employment of mental health counselors is projected to grow 22% in the next decade, much faster than the average for all occupations.

My interpretation of this question, then, is that what is actually lacking in this field is not jobs, but sustainability. How can you work with historically marginalized communities given the systems that exist?

Poverty and mental health

To answer this question, we need to back up and consider why mental health support for people on the margins is so critical.

Poverty is a huge predictor of mental health problems. If you’re constantly worrying about whether you’ll have enough money to pay for rent, food and transportation — and you live in a part of town that is noisier, has fewer resources, is overpoliced and has scant green space — most, if not all, of your energy goes toward survival.

“Your stress response is constantly being activated,” said Sharon Lambert, a professor of applied psychology at the University College Cork in Ireland. “Your body reaches a static load because you only have the capacity to deal with a certain amount of stress. It can make you physically ill, mentally ill.” If you’re living in poverty and also BIPOC, LGBTQ or a woman, this stress burden can be even greater.

Yet those who need quality mental health services the most in the U.S. are the least likely to receive them. A single therapy session can cost anywhere from $100 to $300 if you’re uninsured, and many therapists do not accept insurance, let alone Medicaid, because insurance companies don’t pay them well. Community clinics and nonprofits that provide no-cost or low-cost therapy often have months-long waiting lists. An estimated 54% of American adults with a diagnosed mental health condition do not receive treatment.

If someone is connected to affordable mental health services, there’s a good chance that their clinician will be someone from a higher-income family who doesn’t truly understand their experience, Lambert said. The very high cost of a graduate degree in the U.S., among other factors, means that the mental health field isn’t nearly as culturally diverse as it should be. According to a report from the American Psychological Assn., 86% of U.S. psychologists in 2015 were white, and in 2019, the Bureau of Labor Statistics found that 88% of mental health counselors were white.

Part of the issue is that students training to become therapists take on substantial debt to pursue a graduate degree, and are then asked to work for free during and even after school, to accrue training hours — which just isn’t sustainable, especially for many people of color.

The bottom line is that as long as there is woefully inequitable access to education, healthcare, child care and affordable housing in this country, there will be way, way too many people in poverty suffering from preventable mental health conditions, experts told me — overwhelming agencies that aren’t well-funded enough to meet all of that intense need, staffed by clinicians who are often underpaid, overworked and burned out.

A way forward

So where does this leave people like our reader, who want to support the wellness of the people who need it the most, but also want to maintain their own well-being?

There are many different answers to this question, and none of them are neat and simple. But here are a few suggestions from the experts for how to make a difference:

Focus on upstream work: “We don’t do enough to prevent mental health problems, and when we do get our well-trained workforce, we have too many to serve. It’s a vicious cycle,” said Jerel Calzo, a professor of developmental psychology at San Diego State University. “If we were to invest more in prevention and mental health promotion, it could help undo this a bit more, and make it more sustainable for those who are on the community mental health side.”

This is where advocating for structural and systemic changes — access to universal healthcare, affordable housing, higher education, anti-racism work and so much more — comes in. Advocacy is an integral part of social work in particular, ranging from small-scale actions that help individuals to large-scale programs designed to benefit entire communities.

“How do we change community conditions so that illness and injury don’t happen in the first place?” said Sheila Savannah, managing director of Prevention Institute, a national nonprofit that focuses on health equity. At Prevention Institute, this looks like investing in community-based programs that foster social connections, create economic and educational opportunities, and improve the physical environment of neighborhoods.

Start where you are: Savannah advises people who are entering the mental health field to work in their own community, at least at first.

“Once people see that this could be their own family member struggling with addiction or other mental health struggles, it gives them a different level of empathy,” Savannah said.

An understandable impulse may be to go where the need seems the greatest. But if that’s not your own community, such a choice can play into the power dynamic of “I am the helper, you are the service recipient,” Savannah said.

In traditional mental health care, little attention is paid to the knowledge, strengths and resources that the client could bring to their own healing and that of their communities. The emphasis is instead on the client’s problems, with the clinician in the expert seat. It’s a disempowering setup that reinforces classist and racist systems, Savannah said.

An increasing number of mental health organizations are recognizing that in order to shift this paradigm, members of the communities being served need to be at the table, making decisions and coming up with solutions. The peer-led mental health model in particular continues to gain traction because it showcases the resilience of people living with mental health conditions, and empowers them to be a part of other people’s recovery.

“People feel better when they are contributing as well as receiving,” Savannah said. “This creates a conundrum for someone with traditional clinical training, who hasn’t been taught that when they partner with someone with lived experience, it’s better for their client, for their community. “

Therapist, heal thyself: The mental health field attracts those who have their own healing to do, Savannah said. So making sure that you’re on your own path of recovery is essential, both so that you can prevent burnout and ensure that you’re not unknowingly harming your clients.

“The best clinicians I know are in therapy all the time, as a way to give them new insights into what they’re doing and how they’re doing,” she said.

I know that this newsletter addressed new mental health professionals specifically, but I think everyone can and should play a role in advocating for more equitable, holistic, community-centered mental health services. Every single one of us stands to benefit from a society that listens to and cares for all of its people.

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email [email protected] gets right to our team. As always, find us on Instagram at @latimesforyourmind, where we’ll continue this conversation.

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More perspectives on today’s topic & other resources

My colleague Sarah Parvini has a story out today about the incredible challenge of working as a therapist in L.A. County’s public mental health system. Intense hours, low pay and high caseloads of patients with immense needs are burning out these professionals we desperately need to stay in the public sector. A graduate student in social work at UCLA told Parvini: “I would get a call from a client like, ‘Hey, Tieryn, I’m in the parking lot, and I want to kill myself.’ And then drive to where the client is on the phone. I’ve had clients call me from jail because I was the only phone number that they could remember at the time.”

Not all psychiatric symptoms are caused by stress, but a whole lot of them certainly are, according to Danielle Carr, an assistant professor at the Institute for Society and Genetics at UCLA. “Medicalizing mental health doesn’t work very well if your goal is to address the underlying cause of population-level increases in mental and emotional distress,” Carr writes in this Op-Ed for the New York Times.

The pandemic exposed the disparities in the U.S. mental health system, leaving many Americans without accessible and affordable care as policymakers fail to adequately address the crisis, according to this report from the Center for American Progress that details the issue.

Other interesting stuff

The holidays can have us walking on eggshells around family, or leaving gatherings feeling badly about ourselves or our people. In this episode of “We Can Do Hard Things,” Glennon Doyle and Abby Wambach share their top hacks for getting through the holidays without losing your mind.

Black mental health experts are bringing care to adolescents whose needs often go unaddressed and are misunderstood. The team runs a clinic from an elegant high-rise in downtown Atlanta, where they conduct telehealth visits with young patients and then, among themselves, discuss treatment plans. Such dedicated care — with patients seen in depth, over years — is usually reserved for only the most fortunate.

The homelessness crisis in coastal cities can’t be explained by disproportionate levels of drug use, mental illness or poverty, writes Jerusalem Demsas in the Atlantic. Rather, the most relevant factors in the homelessness crisis are rent prices and vacancy rates.