A new study in the Sage Journal of Health and Social Behaviour reports that social class influences US independent psychotherapists’ decisions of whether to offer access to their mental health services. In the study by Heather Kugelmass, 320 independent providers received voicemail messages from one black working-class service seeker and one white working-class service seeker, OR one from a black middle-class service seeker and one from a white middle-class service seeker. Within both groups, an equal amount of voicemails were from male and female service seekers. The results of the study are summarised in the abstract (partially reproduced below):

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 favoured over men for appointment offers in their preferred time range.

This, as the author also writes, goes against the mental health profession ideal of egalitarianism, which is already purported to be a standard that, in reality, is not lived up to. The fact that healthcare providers, including those working in other areas than mental health, discriminate between patients according to factors such as social class, race and gender such that it influences their decisions about the healthcare they provide, is nothing new to social science. However, what’s special about this study is it is the first field experiment of its kind investigating how this discrimination impacts decisions about who is allowed to access mental health services. Before social scientists can start using this evidence in order to argue for policy changes however, some caveats of the study must be examined and, as usual, further research is required. Note that this article is not going to be an exhaustive analysis and criticism so I will only be commenting on parts that I think may have been overlooked. The original author comments on limitations which may not be apparent in this article- read the original article if you are interested in a fuller analysis.

Firstly, let’s look at the sample of psychotherapists investigated and whether it is representative of the majority of such healthcare providers, so we can generalise about these results fairly. The sample didn’t include psychiatrists, i.e. psychotherapists with medicine degrees. I think this may bias results in that practitioners with a PhD or DClinPsy/PsyD qualification are not expected to take the Hippocratic Oath, unlike those holding MDs. I speculate that this would make a difference, not because other health professionals are any less committed to ethical practice, rather there is some psychological effect of taking the oath which only MDs receive. Their explication of their ethical promise might become more central to their self-concept such that failure to live up to that standard is more psychologically harmful than it would be for those who have managed to better compartmentalise that aspect of self-concept related to professionalism and ethics.

Another fairly speculative issue with the sample is that the type of therapy offered was not measured. Although I cannot speculate on whether therapists offering one type of treatment would be more likely to give access than others, it might still be a confounding variable as therapeutic styles can differ vastly according to the type of training a therapist has undertaken. For example, some therapeutic styles may be better suited to certain patients so therapists may reject access because they believe a patient may benefit more from other services. If this happens to be the case, good ethical practice would be to recommend whatever therapeutic service the practitioner feels would be most appropriate for the patient. I think that if there are conflicts of interest which prevent this kind of practice, it is exemplary of yet another contradiction in capitalism as practitioners would be incentivised not to recommend the services of competing practices, even if they consider them more appropriate, as doing so would be against their self-interest, yet not doing so would be against the interest of the patient.

In addition to issues with the sample, I have some criticisms of the method to address. This experiment was done using voicemails recorded by actors, meaning any interpretation of the class, gender and race of the service seeker, was based on stereotypes. Although the stereotypes used were based on social scientific evidence about how these variables should be implied in the recordings, I feel that even with the evidence that these stereotypes can often seem accurate, studies of this sort always risk reifying and giving legitimacy to the idea that there is a causal association between characteristics of speech and the variables investigated, such as race and social class.

I also think that there is something more to be investigated about how the American healthcare system generally influences healthcare practitioners’ access decisions. Even though the sample used in this study used hypothetical service seekers that would have their services covered by insurance, it would usually be reasonable, even if unfair, for practitioners to consider the social class of potential patients, as it may impact their future income. I predict that practitioners’ perceptions of service seeker social class would be less influential in countries with universal healthcare systems, such as here in the UK. However, Kugelmass does address this, noting how even under a universal healthcare system, specifically in Canada, there is evidence that discrimination between patients by social class happens- this could be due to cultural homogeneity between the US and Canada being stronger than between the US and UK or other European countries where universal healthcare has been a norm for considerably longer. Financial considerations are also noted as a possible explanation for why the discrimination happens, other than the social psychological explanations briefly discussed in the report.

If you are interested in this discussion, I highly recommend reading the paper which will be referenced at the end of this article, as Kugelmass’ writing includes important references to the scientific literature and there is plenty of discussion of the limitations of the study not mentioned by me, which show that Kugelmass is self-aware, and hopefully this article doesn’t imply otherwise. I agree with her that this work is both important and necessary for researchers of social inequalities. Moreover, although I agree this potential research programme is in its infancy, she should be commended on designing a study which looks cheaply replicable, something difficult to come by in social science.

Reference: “Sorry, I’m Not Accepting New Patients”: An Audit Study of Access to Mental Health Care by Heather Kugelmass. SAGE Journal of Health and Social Behaviour 2016 Vol. 57 (2) 168-83.