Here’s how psychologists are serving patients with lower incomes

People in lower income brackets have suffered disproportionately throughout the Covid-19 pandemic, reporting higher numbers of mental health challenges due to stress (Benton, A., et al., Health and Human Services, 2021opens in new window).

Yet too few psychologists tend to work with lower-income and economically marginalized (LIEM) patients; many psychologists come from affluent backgrounds and do not consider expanding their services outside their own socioeconomic level, says Bettina Spencer, PhD, a professor of psychology at Saint Mary’s College in Notre Dame, Indiana, and the current chair of APA’s Committee on Socioeconomic Status.

Almost two thirds of psychologists rarely serve those earning the lowest incomes, and most have never worked with people facing housing instability, according to APA’s 2018 A Summary of Psychologist Workforce Projections report (PDF, 395KB)opens in new window.

“If you look at who goes to graduate school and then who completes [a degree], it is not a very diverse pathway. A big problem, not just in psychology but in other medical fields, is that the people who become the practitioners haven’t interacted with people with lower incomes,” said Spencer.

As a result, psychologists often treat people who already have insurance or can pay out of pocket, whose problems they understand, and at hours and locations that are compatible with moderate- and higher-income lifestyles.

The demand for psychologists has risen during the Covid-19 pandemic, including for LIEM patients (APA, Covid-19 Practitioner Impact Survey, 2021). There is a shortage of psychologists available to meet demand, and it may be difficult for providers to accommodate patients who might need pro bono or sliding-fee scale options due to financial strain. Generally, there are fewer psychologists who choose to carve out a specific number of slots for LIEM patients, especially those without any insurance options. Overall, psychologists need more specialized training and guidance on ways to set up their practices to serve these populations, said Spencer.

Most important, psychological services must be considered something that can be available to everyone, not just to people who have resources to pay for it, said Cindy Juntunen, PhD, a psychologist and dean at the University of North Dakota and a task force member of the APA’s Committee on Socioeconomic Status, which helped create the 2019 guidelines (PDF, 478KB)opens in new window on serving patients with LIEM backgrounds.

APA’s guidelines explain the need for psychologists and trainees to increase their knowledge and training on economic marginalization and look for ways to serve patients that challenge their own implicit biases around social class and poverty.

“Income disparities continue to be a real potential area where stigma can develop. And mental health providers, just like almost any other provider, unfortunately, tend to have negative perceptions of people with low incomes,” Juntunen said. “Now, I think that’s changing, thankfully. A lot of psychologists actually are very concerned about economic disparities and are really actively trying to become more accessible.”

Payment is one of the biggest barriers to treating patients with LIEM backgrounds. In 2020, there were more than 31 million people living in the United States with no health insurance (Cha, A., et al., National Health Statistics Reports, No. 169, 2022 [PDF, 464 KB]opens in new window). In 2022, that number had decreased 16%, to more than 26 million people across the United States who were uninsured (Cohen, R., et al., National Center for Health Statistics, 2022 [PDF, 247KB]opens in new window).

However, that is still a sizable gap in coverage and does not account for the challenges of people who are underinsured. People with lower incomes might be insured through their jobs, for example, but struggle with such high deductibles that the cost of a therapy visit may still be unaffordable. Nevertheless, reports show that it is common for people with LIEM backgrounds to spend thousands of dollars on appointments if they are dealing with mental health crises.

A 2019 report from the Mental Health Treatment and Research Institute (PDF, 6.31MB)opens in new window found there is also a significant number of people, especially children, who are not using insurance to seek behavioral health care, and those out-of-pocket expenses can lead to high medical debt. The report found that by 2017, a behavioral health care office visit for a child was about 10 times more likely to be out of network—twice the likelihood as those for adults.

Rachael Soule, JD, director of business regulations and independent practice in APA’s Practice Directorate, said APA has been pushing for policymakers to increase health care reimbursement rates to expand care.

“The biggest issue for why there is lack of access to care and why [many] practitioners aren’t in Medicaid networks is because reimbursement rates are so low,” Soule said.

According to the American Hospital Associationopens in new window, hospitals received payment of only 88 cents for every dollar spent caring for Medicaid patients in 2020, resulting in billions of dollars of underpayment (Fact Sheet: Underpayment by Medicare and Medicaid, 2022 [PDF, 334KB]opens in new window).

Soule said increasing reimbursement rates for services offered under Medicaid, Medicare, or any insurance would likely lead to more behavioral health care providers accepting insurance from their patients.

To accomplish this, Soule urges psychologists to get involved with APA’s advocacy efforts to increase reimbursement as well as with their state associations. She also advises psychologists to find out if their state offers incentives for serving patients with LIEM backgrounds. For example, Oregon has a behavioral health loan repayment programopens in new window that offers providers a tax-free award of funds to help them repay qualifying undergraduate or postgraduate loan debt in exchange for 2 years of service within underserved communities and for people who are underinsured or on Medicaid or Medicare.

One success story is Open Path Psychotherapy Collective, founded by therapist Paul Fugelsang, MA, LMHC, of Asheville, North Carolina, in 2012. The North Carolina–based nonprofit connects mental health professionals, including psychologists, all over the United States and Canada to people who need help affording mental health services.

The collective aims to help patients who are underinsured and uninsured whose incomes are not low enough to qualify for community mental health services. “There’s this wide group of people in between . . . and there’s really not a whole lot out there for them,” said Fugelsang.

Open Path includes more than 19,000 providers throughout the United States and Canada who are willing to offer underinsured or uninsured people therapy at a low cost. Individuals pay one $65 fee to have lifetime access to the directory of providers willing to take on LIEM patients. Therapists take home the entire cost of the appointment.

There is no fee for a psychologist to sign up with Open Path. To participate, therapists need to be a licensed or provisionally licensed mental health clinician with a graduate degree in psychotherapy, counseling, or a related field from an accredited institution. And they must pass a peer-reviewed online applicationopens in new window. Open Path sets the sliding scale rates to be $40 to $70 for individuals and $40 to $80 for couples and family for a standard 50-minute session.

Fugelsang started Open Path because he realized he could not serve as many LIEM patients as he wanted and keep his practice afloat. He had opened a few slots in his private practice for patients who needed to pay a lower price, but demand was higher than what he could afford to offer. And he found it difficult to refer patients to other psychologists because there was no directory that showed which providers also offered low-fee slots or a sliding scale for fees.

“Once you join up with the collective, there’s a sense of a larger mission,” he said.

One psychologist who works with the collective, Negar Nazari, PhD, based in San Diego, treats several patients she connected with via the platform. Before she begins therapy, she talks to patients with LIEM backgrounds about what they can afford to pay.

“I don’t set a rigid price because I want to make it accessible. So, if at the end of the day, they’re going to pay a little bit less but are going to be able to commit, that’s what matters,” Nazari said. “We’ll adjust it as we need to and account for the gas if they were seeing me in office or if they’re needing to see me more frequently.”

Juntunen said it can be hard to convince recent graduates to serve LIEM patients when they are faced with the need to pay off graduate school debt. For example, Shilpa Trivedi, PsyD, a licensed psychologist in Houston who serves mostly patients with LIEM backgrounds in her practice, says the no-show rate for LIEM patients can be high. And when a patient does not show up, the provider ends up eating the cost because Medicaid does not reimburse for missed appointments.

“You can never rely on just one income source because it can dry up very quickly,” she said.

To help meet the need, Juntunen said more training programs should teach students how to sustainably work with this population and how to set up a practice that can serve them.

“In our program, one of the things we tell students is that part of our admission and training process is a commitment to social justice, and that it’s a key aspect of being successful in our training model,” she said. “The desire is often there because these are folks who want to get psychology out to the world.”

Mindi Thompson, PhD, is a counseling psychology professor at the University of Wisconsin–Madison and a member of APA’s Committee on Socioeconomic Status. Within her research program, she and her students focus on examining the role of social class in psychotherapy and how psychotherapists’ perceptions of patients change based on their social class.

“There are a number of biases that many of us hold, especially growing up in the United States. The myth of meritocracy certainly is inherently embedded in all sorts of places,” Thompson said. “I’ve worked with many individuals in the past who don’t realize that bias exists or hadn’t ever thought about it in that way.”

Another way psychologists can better serve people with lower incomes is to make appointments easier for them to attend. Psychologists are now reimbursed for audio-only and videoconferencing visits by many insurers (U.S. Department of Health and Human Services, 2021opens in new window), Medicaid, and Medicare (Centers for Medicare and Medicaid Servicesopens in new window). Telehealth can often be easier to schedule for patients who may not have reliable access to transportation. It is also a way to serve people who may not be able to leave home because of lack of childcare options or disabilities.

Trivedi said psychologists who want to serve LIEM patients can be proactive by finding office space that is centrally located and on a bus line.

She said it is also important for psychologists working with LIEM patients to secure multiple streams of income. One way is to diversify one’s practice—make marketing a priority, accept several different types of insurance, and develop multiple referral sources.

Trivedi also works closely with social service agencies that have a behavioral health component, like those focused on children in the foster care system. “I did a lot of cold-calling agencies and introducing myself,” to let them know she has expertise in working with LIEM patients, she said.

Another challenge of working with LIEM patients can be the intensity of the work. Psychologist Pratyusha Tummala-Narra, PhD, a research professor in the Department of Psychological and Brain Sciences at Boston University, works with people with lower incomes, as well as with members of immigrant and diverse communities, and finds that many people with lower incomes often do not see a mental health professional until their needs become urgent; the delay is often due to lack of access to resources, stigma, or concerns about receiving adequate treatment. Some immigrant patients, she said, may also not seek help because of fears over documentation.

“Emotional stress is often not identified until it reaches crisis level. So sometimes what we see is people seeking out help because they see a primary-care doctor, or they go to the emergency room. These are some of the internal cultural barriers that we see in communities,” she said.

Tummala-Narra is working on developing a community mental health education program at the Albert and Jessie Danielsen Institute at Boston University so that she can disseminate much-needed information to the various communities, including immigrant communities, that might need to seek ways of coping. The hope is that this tool may increase public knowledge about identifying mental health concerns and resources that can help in coping with emotional distress.

Tummala-Narra says serving patients from lower-income backgrounds is rewarding and at times challenging.

“I also grew up in an Indian American community where issues of mental health and trauma were highly stigmatized,” she said, noting that many of her patients struggling to access therapy really need someone to reach out to them and understand their lived experience.

“Clients are struggling with longer-term issues like trauma and difficult relationships, depression, anxiety [and] I think longer-term therapies really need to be made more accessible to people who have fewer resources.”