Finding a person to declare your craziest, most profound insecurities to is not exactly a picnic. But the bureaucratic idiocy of America’s healthcare system turns what should be a chore into torture.
If you’re a middle-class person in America, the dance goes like this: You call your insurance provider to find a meager list of therapists who take your insurance. Most of the people on the list are licensed clinical social workers or licensed mental health counselors. They can be wonderful and very helpful, but they often have less schooling and experience than, say, psychologists and PhDs. After digging deeper, you find that some of these therapists don’t take your insurance after all; others have full client lists. And even if they do have space in the day to treat someone, they might not be interested in treating you. According to one study, a low-income Black person had up to an 80 percent lower chance of receiving a callback for an appointment than a middle-class white person. And even though intellectually, therapists tell you that anger can be a helpful and legitimate emotion in processing trauma, God forbid you actually seem angry on the phone. Several mental health professionals have told me that therapists often avoid rageful clients because they seem threatening or scary.
Therapists instead prefer to take on YAVIS—Young, Attractive, Verbal, Intelligent, and Successful clients. They love an amenable type, someone who is curious about their internal workings and eager to plumb them, someone who’s already read articles in The New Yorker about psychology to familiarize them with the language of metacognition and congruence. Good luck if you’re a regular-ass Joe who’d rather watch It’s Always Sunny in Philadelphia.
But say you get lucky and find a licensed clinical psychologist with an open slot. The psychologist is white, of course (86 percent of psychologists in the United States are), which isn’t ideal if you are a person of color. But, fine, whatever: You just need to receive an official diagnosis for your insurance. You are certain you have complex PTSD, but he can’t diagnose you with that because it’s not in the Diagnostic and Statistical Manual of Mental Disorders. Your insurance only covers treatment for conditions listed in the DSM in order to assign a number of sessions to you. Most forms of insurance will pay for, say, only six months of therapy relating to anxiety, ten for depression, as if you should be better by then. Another consequence of C-PTSD not being in the DSM: This psychologist hasn’t been trained in treating it. He says he doesn’t believe that it’s a real diagnosis. He’d like to provide you with some questionnaires to see if you have something he can actually handle—bipolar disorder, maybe, or manic depression. This does not inspire confidence, so you leave.
After some internet sleuthing, you find a woman of color who seems really cool. She’s specifically trained in the treatment of complex trauma. She has blurbs on her website that resonate with you—it seems as if she might truly understand you. But she doesn’t take insurance. (Psychologists are the least likely of any medical provider to take insurance—only about 45 percent of them do. And most of the time, the ones who don’t are the most qualified practitioners.) You can’t exactly blame her. You learn on the internet that insurance companies haven’t updated reimbursement rates for therapists in up to twenty years, despite rising rates for office rent and other administrative costs. If therapists were to rely on reimbursement rates from insurance alone, they’d wind up making about $50,000 a year on average, which is fine, but like, not great if you’re an actual doctor.