Too Poor to Pay for Peace of Mind

Anacostia is a neighborhood in Southeast Washington, D.C., where life spills unassumingly onto the sidewalks in front of barber shops and cafes, churches and liquor stores, schools and small businesses. It’s a working-class community alive with the synergy of folks just getting by, grabbing at pieces of joy along the way.

Authenticity is its culture, particularly compared with other parts of the city being blitzed by gentrification. Like many urban enclaves, financial and social factors complicate residents’ pursuit of happiness. 

The black population in the District is 49.5 percent. The black population in Anacostia is 94 percent.

The median household income in the District is $64,267. The median household income in Anacostia is $32,262, down by nearly $3,000 in the past two years. The D.C. unemployment rate is 7.7 percent. Anacostia’s is 35 percent.

Those statistics distilled into real life mean there are many black people in a relatively small area making a lot less money, if any money at all, than other people in the District, this as rents approach prohibitive figures citywide. The number of apartments and condominiums in the District commanding rents of $1,000 or more per month has doubled in less than 10 years, but cost-of-living increases, for most people, are the stuff of wishful thinking and yet-unanswered prayer. It’s a cocktail of stressors that exacerbates the urgency of the need for mental-health care. But the people who need it generally can’t afford it. It’s an issue in Anacostia as much as it is in Philadelphia, Detroit, Chicago, Baltimore and other metropolises where too many black people are suffocating under the pressures of being broke.

Satira Streeter, executive director of Ascensions Psychological and Community Services, has been an advocate for mental health in Anacostia for more than 10 years. Because it is a nonprofit entity, Streeter’s organization is a model for making clinical psychology available to communities in urgent need. Many of her colleagues wouldn’t slide out of bed for the $25 co-pay her office charges clients, much less venture into some of the city’s most economically and socially challenged neighborhoods for that amount of money, and her colleagues have told her as much. “One of the things we do that’s different is accept Medicaid and all insurance companies. But if you don’t have insurance, what do you do about your mental-health care?” she said.

It’s been a running question since Streeter, a psychologist, founded the practice in 2004 specifically to help African Americans handle the systemic effects of poverty and racism. She’s seen an uptick in clientele since the implementation of the Affordable Care Act, the so-called Obamacare, which has helped her treat more people for depression—the condition she sees most often—and take on individuals and families. Such care can be life-changing for the people with the insight to seek it and the means to pay for it. “I had a client just yesterday who said, ‘Yes, I have insurance, but I can’t appropriate $25 for the co-pay for therapy when I have three children. If I have to make a choice, the mental-health care will have to go, even though I need it.’ They have to make a decision to provide for the physical needs of their families,” Streeter said.

It’s another unfortunate consequence of financial struggle that feeds the cycle of disadvantage. And yet there is also such a thing as not being poor enough.

“If you’re middle class, making $55,000 or $60,000—depending on where you live—and you have insurance, they’ll say ‘yes’ to seven, maybe 10 sessions. But if you have real problems, that’s not enough,” said Jasmyn Price, a licensed clinical professional counselor in Maryland. “Mental health is sort of like the news media: If it bleeds, it leads. If there are extreme problems, like drug abuse, domestic violence, child neglect, those are the kinds of things that they are thrilled to start nonprofits and focus their attention on,” Price said. “You can even get service at your house if you are low-income. But if you’re less poor, you don’t get the same kind of attention.” For lower-income and categorically middle-class people, preventive care is hard to come by. There’s little opportunity to intuit a need to talk to a professional therapist and address struggles early on. A condition either has to be present or escalate in a moderate to severe way before it can be treated. By then, it may have wreaked havoc on the individual directly suffering, disrupting his or her home life, job and source of income. “If you are having trouble with your child or you’re just kind of borderline depressed, that’s called a V or Z code, and insurance companies are like, ‘We’re not really trying to pay for that. You probably should be able to work that out on your own,’” said Price. “Let’s say you were to get insurance through Obamacare. Even if you went to an independent therapist, they would diagnose you with a more serious disorder in order to be able to bill your insurance company, because most will not pay for V code.” Folks walking around approaching about-to-snap-the-hell-out status because they can’t get access to mental-health services aren’t necessarily menaces to society. Sometimes they lapse into helpless depression or simmer quietly in undiagnosed dysfunction. There are instances, however, when they’ve become dangerous to themselves and their communities. If we’re genuinely investing in underserved neighborhoods—Anacostia and others like it across the country—we have to offer everyone mental and emotional healing, particularly as advocates work to obliterate the cultural stigmas that shame those affected by mental illness and keep them from seeking therapy in the first place. What’s pricier: providing mental-health services or living with the results of not giving people in poverty access to those services at all?