“Can I have her ID back, please?”
I all but snatched the driver’s license from the receptionist and handed back it to Dahiana Rojas, a 25-year-old Latinx health aide who works with developmentally disabled people in New York. “We’ll figure something else out,” I told her.
We were standing at the Helen Atkinson Health Center—the clinic in Harlem where we were inquiring about therapy—and the person behind the desk had just finished telling Rojas that there was a new patient appointment available in two weeks, and that it would cost $120 for her first visit and $80 per weekly appointment thereafter. Despite being sliding scale pricing, it was steep considering her income. This was the 8th place we’d checked, and I was at the end of my rope.
It had been about a month since I promised to help Rojas, who’s now a friend, find a therapist in New York after she confided in me about her anxiety and depression. I was becoming frustrated. I’d come across research about how hard it is for young people of color to find and keep a therapist, and I’d experienced it myself. But it still felt jarring to be clawing at clinic doors in what’s supposed to be one of the most progressive cities in the world.
I met Rojas six years ago when I was her writing tutor. After watching her breeze through her first year of community college, I moved out of state and we lost touch. When we reconnected a year ago, I was surprised to hear she’d put a pin in her education and gotten a job.
The topic of therapy came up naturally, as we caught up over frozen yogurt one evening last July. She told me about how her anxiety had recently worsened and was now manifesting itself in physical symptoms such as panic attacks. “During those times, I can’t talk. I can’t communicate. I just have to let it ride out, and it’s terrifying,” she said, her tone despondent. “Not being able to breathe right makes you feel like you’re going to die.”
Rojas had never seen a therapist, and wanted to. “I’m doing the affirmations and mantras and stuff, but there’s something deeper I just can’t get to,” she said. “I need to figure out how to handle my triggers.” She was already crushing the pre-requisites: She knew exactly how to name the beast—she’d read enough to know what was likely afflicting her—and now wanted to tame it.
Last summer, Rojas was making $450 a week, after taxes. She didn’t have insurance—she used to have Obamacare, but behavioral health wasn’t covered on the bronze plan she could barely afford, so she axed it entirely. If a community clinic in Manhattan had two counselors to go around, and they wanted this much money from her based on her income, was our quest doomed?
This wasn’t my first time acting as a therapy sherpa. I’ve taught writing at colleges in several different cities, and every semester at least one student has inquired about how to find a therapist. There are always roadblocks: insurance, parents’ disapproval, long waitlists at the university’s clinics, or straight-up embarrassment. And another thing—the people seeking my help were all students of color.
I’d always made suggestions and offered emotional support, but none of them had ever followed up to tell me they were settled into a therapy routine. When I offered to help Rojas, I decided to crack open the inquiry: Why is it so challenging for young people of color to get therapy?
It’s easy to point to the socioeconomic factors that disproportionately affect young POCs’ wellbeing: Households headed by Black Americans “are at least twice as likely as whites to be poor or to be unemployed.” And the wealth gap between white and Latinx households is still a significant one. Much of this points to a history of systemic inequality—to phrase it gently—whose tentacles have stretched into several aspects of young Black and brown people’s health today. But money and class are only a part of the race-related accessibility problems in mental health care.
Young Black and Latinx people in the U.S. have a very different relationship with mental illness than their white peers, including higher rates of attempted suicide. And in communities of color, it’s still largely taboo to talk about mental illness openly, let alone seek help for it. Data shows that many of these young people don’t seek it, or when they do, have very limited access.
“For African Americans and other young people of color, the stigma really manifests in a couple of ways,” said Alfiee Breland-Noble, a psychologist and mental health disparities researcher at Georgetown University’s Center for Trauma and the Community. “One is that many of us don’t see mental illness as a physical or physiological health problem.”
There’s a strong body of research (which includes much of Breland-Noble’s work) that’s referred to as “treatment engagement”: How do you get and keep people in therapy? “We don’t necessarily, in general, buy into the idea that [mental illness] is hereditary, it’s genetic, and there are chemical components. And so the idea is that if it’s not a ‘medical illness,’ why do you need to go see a doctor for it?” Breland-Noble said.
Jamir Milligan was a 19-year-old student living outside Philly when he first sought out therapy. He struggled with “classically millennial identity issues,” as he described them. “I knew I was brought into this world for great things, but I wasn’t experiencing that on the day-to-day,” Jamir, now 28 and working in media technology, said. “And then I was in a tough relationship where the girl I was dating kind of used that—the knowledge of what I was going through—to her advantage, which ultimately turned into me wanting to commit suicide.”
Jamir wanted to try and make sense of all of it—and thought a therapist might offer unbiased help. “Once I actually began going to therapy, finding someone who genuinely aligned with my concerns was an uphill battle,” he said, referring to the few he saw before finding a clinician who fit. And while his therapy was covered by insurance, the co-pays sometimes didn’t fit into his budget. Yet when he missed a session, he felt like he was sacrificing his overall wellness.
Just getting to that first session, though, was challenging. Jamir told me that he didn’t have any friends or family members who’d been to therapy, so everything was self-guided. “My mom is a preacher and she never made me feel like it would be weird,” Jamir said. “But internally you kind of just have that feeling.”
“That feeling,” as I and so many other Black and brown people know, is centuries’ worth of shame surrounding mental illness—especially depression, which is what Jamir was primarily dealing with. Depending on your background, depression and other mental illnesses have been addressed in a plethora of ways, including praying it away in Black, Latinx, and South Asian cultures, self-medicating, or just ignoring it.
“I think we have culturally sanctioned ways in which we cope, and none of those include traditional forms of talk therapy,” Breland-Noble said. She finds that there’s huge resistance, spanning multiple generations, that can be summed up as, “We don’t do that. That’s what white people do.” One of Breland-Noble’s therapy clients, a Filipino teenager, once told her that her parents referred to what she was going through (an anxiety disorder) as “first world problems.”
“A lot of the Latin American community does not necessarily agree with therapy, especially for men. You’re called a ‘maricon’—a vulgar term meaning ‘faggot’—which then triggers people who are in the LGBTQ+ community,” said Pablo Zuniga, a 27-year-old Guatemalan-American from Redwood City, California. “I’ve faced this many times when I would bring up therapy to my family. It was only accepted when I [told them] that at one point in time, I considered self-harm.”
Pablo recalled, specifically, trying to tell his mother about his depression when he was 19. “I told her, ‘I think I need therapy. I’ve been feeling sad. There are a lot of issues that I’m ignoring, and I hate feeling like this,’” he said. Pablo’s mother wondered why. “She told me that her life was so much harder than ours, and how all the challenges that my sister and I face are nothing compared to what she did.”
“I’m also the child of immigrants and this conversation is not unfamiliar to me,” said Harrald Magny, a New York City-based psychologist. Magny is young, Black, and has had several clients like Pablo, who are fed the idea that they should sack up because their life isn’t hard compared to the previous generation’s. Magny stressed that the immigrant experience was traumatizing yet transformative for so many, including his own parents. Ultimately, though, he said that parents who dismiss the idea of their kids seeking help are poorly educated about what therapy actually is.
As Breland-Noble put it, seeking help indicates weakness in a cultural narrative where weakness has never been an option. “The societal expectations of Black men are a hyperbolic extension of the emotional standards men are held to,” Jamir told me. “Black men are portrayed as hyper-masculine, almost anti-emotional, and that affects the way we see ourselves and the range of emotions we’re able to show.”
Stigma is merely one part of the battle for every student I’ve tried to help, and every person I spoke to for this story. There were also the matters of money and accessibility.
I can confidently say that the struggle is real if you don’t have insurance. It ultimately took Rojas and I two months to find her an affordable therapist after visiting and calling more than 14 places that offer a sliding scale payment system. If you have insurance you purchased as a part of the Trump-era ACA, getting therapy can still be nearly impossible, since the mid- and lower-tier plans don’t cover it until you get a $5,700 deductible out of the way.
Research from 2016 shows that Black and Latinx Americans have had “persistently lower insurance coverage rates at all ages” and that even people who do get insurance at certain points in life are significantly more likely than their white counterparts to lose it. Even after the ACA was passed, the disparities in insurance coverage for Latinx people are alarming.
When I bring up accessibility, I’m not just talking about disparity in counseling services available in your neck of the woods, but also “a mental health system weighted heavily towards non-minority values and culture norms,” as NAMI puts it. This means that therapy and most mental illness diagnostic screenings, until quite recently, were designed for white people. They often don’t account for differences in values, norms, or variations in verbal and nonverbal expression.
Even more egregious is the seemingly unconscious discrimination that a mental health practitioner might exhibit, even before the first meeting. In a phone-based experiment that the Atlantic reported on, researchers had voice actors try to make first-time appointments with therapists. Even after controlling for variables like stated insurance coverage, the researchers found that Black voice actors—purposely distinguished by Black-accented English—were “significantly less likely than whites to be offered an appointment.”
Still, it’s encouraging that more young people of color are vocal about wanting help. And the system, however slowly, is making “considerable progress in addressing gaps in research, training, and the provision of culturally sensitive mental health treatment,” said Lakeisha Sumner, a clinical psychologist at UCLA, and a member of the American Psychological Association. Sumner, who works with a diverse group of students, told me she’s inspired by their perspective on mental health. “Many of them are proactive in seeking treatment and often pursue psychotherapy as a preventive measure in strengthening their ability to take better care of themselves.”
Rojas ultimately landed with a 20-something Black woman therapist, a grad student training at NYU, and it felt right to her. On a rainy morning in September, I accompanied her to her first appointment at a church in midtown (the counseling is church-sponsored, but not religion-based). It was the only program we found in the city that was taking new clients who don’t have insurance. At $35 dollars a session, it was manageable.
Talk therapy can take several weeks or months to take any effect. But as I sat in a lumpy chair in the musty church hallway, waiting for Rojas walk out of her first session, I wanted magic. I wanted her to skip out and say to me, “I have the tools now! I’m going to be great! No more shortness of breath!”
Of course, she just walked out with the nervous smile she walked in with. At that point though, just having a therapist locked down felt like magic. Several months in, she’s updated me on the good, weird, uncomfortable, and very useful parts of her sessions. We’ve also talked about the disturbing nature of how hard it was to get there. “Even if I can’t afford their services, isn’t it their job as a person in the healthcare field to suggest an alternative?” she said. “It’s frustrating. I felt kind of helpless. Even when I went out to seek help, it felt like no one was willing to help me.”