As mental health resources dwindle, where’s a low-income person to go?

When I went through training to be a counseling psychologist is the late 1980’s, we covered every diversity dimension except for class and disability.  While I had been concerned about class issues my whole life, I became acutely aware of how this played out in therapy work when I worked at the counseling center at Iowa State University.

One depressed client shared that while growing up in poverty, he had to eat bologna for lunch daily, which left him feeling that he did not deserve much in life in general.

Another student from the Veterinary Medicine College described feeling shy about interacting with Vet students from more privileged backgrounds. Getting into this Vet school is a feat harder than getting into medical school, and I encouraged her to feel pride because she was able to get there from less privilege.  I suggested that she interact with others from that perspective and I could see her light up with surprise and hope.

But access to psychiatric care and psychotherapy is severely limited for those living with low incomes or in poverty.  There are states like Iowa that have a shortage of psychiatrists to begin with.   During a recent five-year span, as the U.S. population grew nearly 5 percent, the number of psychiatrists barely increased.

We have a system in which the least experienced and trained counselors are serving the most severely injured and least resourced clients. The reason is that therapists-in-training are willing to be paid less at Community Mental Health centers or in facilities that accept Medicaid and Medicare while they are getting their supervision.

There are exceptions, with dedicated, experienced folks being willing to make less money. But many therapists in private practice limit the number of Medicaid clients and military clients they take, because the pay is significantly less than what they can get from private insurance, and in doing so, they violate the contracts with those insurance providers. Medicare reimbursement for a 50 minute psychotherapy session with a psychologist is down 36% since 2000.Some therapy professions lobby to ensure that Medicaid and Medicare payments stay at a level that some practitioners will still be willing to accept those payments.

In Ames, we lost a psychiatry practice due to low government payments and most current psychiatrists don’t take any Medicaid or Medicare patients, leaving the medication management to family practice and internal medicine physicians.

On the positive side, The Hennepin County Mental Health Center in Minneapolis has created a drop-in center for psychiatric care.  It was honored as a “model practice” by the National Association of County and City Health Officials; and perhaps more cities will follow this example.

If the government could put more resources into both increasing payments to practitioners and providing financial help for those professionals who have completed their training, but still need supervision for licensure, then we can expand mental health access to all. Pressure from citizens is what is needed to effect that change.

If you would like to read more about class and mental health, I recommend the following resources:
• Barbara Jensen (2012) Reading Classes: On Culture and Classism in America (available from Class Action,
• William M. Liu (2011), Social Class and Classism in the Helping Professions: Research, Theory, and Practice.
• Laura Smith (2010). Psychology, poverty, and the end of social exclusion: Putting our practice to work.
• Debbie Strum and Donna Gibson, Eds (2012): Social Class and the Helping Professions: A Clinician’s Guide to Navigating the Landscape of Class in America
• Reference for the information on Hennepin County and the national psychiatry shortage –  Ames Tribune, Sunday October 12, 2014, “Minute-clinics for mental health care pioneer in giving quick relief to patients,”   by Allie Shah of the Minneapolis Star Tribune.


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