In San Francisco, it seems more strange to know someone who doesn’t want to go to therapy than someone who does.
In a liberal-minded city like ours, the social stigma against seeking help for your mental health has fallen by the wayside much more in recent years than in many other pockets of our country. That’s not to say it’s not still difficult for many people to take the first step in finding a therapist, but overall, it’s become much more accepted here.
That’s a good thing because — you might have noticed — the Bay Area can be a tough environment to live in, with the pressures of high-stress jobs, a notoriously difficult dating pool, the highest rents in the country and other factors that can take a serious toll on your mind. Worldwide, already one in four people suffers from a mental-health disorder. Add in city living — with its excessive noise, crowds, commuting and general chaos—and that can cause even greater rates of anxiety and mood disorders.
Given the density of wealth here and the high cost of living, the vast majority of San Francisco–based therapists can’t afford to take insurance, which pays significantly less than private pay, leaving the pool shallow if you’re not wealthy.
Plus, we have Silicon Valley and its general ethos. Countless essays have been written about the negative effects that aggressive entrepreneurship, competition and innovation can have on someone’s mind. And that’s to say nothing of the enormous mental-illness issues so prevalent on the streets of our city. We see the dramatic impacts of this city’s mental-health crisis every day.
Despite the challenges, millennials—considered the most anxious generation — are generally open to the idea of getting help (70 percent of those surveyed said they would be comfortable visiting a therapist). But the problem is that when we do resolve to get help, it’s often a long and uphill battle to find a therapist — especially one we can afford.
Given the density of wealth here and high cost of living, the vast majority of San Francisco–based therapists can’t afford to take insurance, which pays significantly less than private pay, leaving the pool shallow if you’re not wealthy.
I’ve experienced this firsthand. After over five years in San Francisco, I’ve seen four therapists, with various Goldilocks-esque outcomes: the first was too robotic; the second too casual; the third too Zen; the fourth a good fit so far (fingers crossed). Three of them accepted insurance, but for the one who didn’t, I paid her over $400 a month (which, all things considered, isn’t bad for SF).
It’s clear that the current state of therapy is San Francisco is in crisis mode — and we shouldn’t pretend it’s anything less than that.
I figured I couldn’t be the only one who couldn’t find a therapist who ticked the affordability and likability boxes simultaneously. That thought was confirmed after The Bold Italic asked people on Twitter whether they had found it difficult to find affordable therapy in San Francisco and the responses poured in, one message after another, from people infuriated and exhausted by their searches.
One woman who messaged us said she found the process of finding a therapist in itself “traumatic” after hours of failed searching (“I was so depressed that the thought of calling a zillion more therapists again was too daunting,” she wrote). Another reader, a Muslim woman of color, said only one of four therapists she’s seen seemed open minded about her cultural background (“One actually made fun of me for my anxiety, and one of them just disappeared after two sessions,” she said.) The stories continued: someone who had to move to the East Bay to get consistent help, while others going on 3, 5 or 10 years have had no luck at all.
In one of the richest, most progressive cities in the nation, these tales are more than heartbreaking; they are unacceptable. It’s clear that the current state of therapy is San Francisco is in crisis mode — and we shouldn’t pretend it’s anything less than that. The question is, What will it take to actually fix it?
Seattle native Amanda Jowers,* who moved to San Francisco for a job in 2014, was a self-described “proponent of therapy,” though she had never visited a therapist herself. But given the transition to a new city, the pressures of a new job and some difficult family news, she decided to seek help.
Given that she was one of the lucky ones who had health insurance, she figured it wouldn’t be too hard to find a therapist. Unfortunately, of the 15 people whom her insurer recommended, most told her they no longer accepted her insurance or were not taking on new patients — and even once she did find someone to accept her, it wasn’t a good fit. Eventually, she gave up. In 2017, Jowers moved back to Seattle and found a therapist there whom she saw until her mental health improved.
“I remember feeling so frustrated,” Jowers said. “I had finally resolved myself to talk to someone, and I was getting rejected left and right,” she said. “I think my experience with therapy in San Francisco just reinforced my feeling that there is still a lot of work to do on mental health and the system. It feels so broken.”
Hers is a common story. So what is it about San Francisco that makes the search for a therapist seem so impossible?
“As therapists gain popularity, they are highly incentivized to switch over to the cash market,” Davis said. “The payback from insurance is not a sustainable wage for a mental health professional in this city.”
It’s certainly not the number of providers. There are over 23,000 licensed mental-health professionals in the greater Bay Area. That’s more than any other region of California, including Los Angeles, Orange County and San Diego. We’re a city with multiple renowned mental-health institutions, including UCSF, USF and CIIS. Some even say this city invented modern therapy.
Turns out, the root of the issue is the lack of providers at a decent price range who accept insurance. SF-based pediatrician Adam Davis, MD says finding in-network options is difficult primarily because reimbursements from insurance companies for counseling are about half of what a non-insurance practice would charge. Out-of-pocket therapy ranges from $150 to $200 per 45-minute appointment here, and insurance companies back them only about $80 per hour.
“As therapists gain popularity, they are highly incentivized to switch over to the cash market,” Davis said. “The payback from insurance is not a sustainable wage for a mental health professional in this city.”
Health advocate R. Ruth Linden, PhD and owner of Tree of Life Health Advocates, echoed Blake’s sentiment. After more than 20 years in health care and a career spent teaching medical students, Linden has watched this issue balloon.
“Very few individuals and very few excellent, experienced, top-of-their-game providers contract with health-insurance providers, because the money is so poor,” she said. “It’s easy to understand why a professional doesn’t want to accept a third or a quarter of their market rate.”
In early October, Linden took a client of hers to visit a psychiatrist in San Francisco, where they spent two hours and fifteen minutes and received a bill of $725.
“That’s not an outrageous fee, if you think about it,” Linden explained, noting that you could easily be billed $200 at a 15-minute primary-care appointment in this city. “That psychiatrist’s rate isn’t that crazy; that’s what has happened to the costs of these services.”
As Davis puts it, the concentration of wealth in the Bay Area has propped up a market that can afford to pay these out-of-pocket rates — sustaining prices that many of us struggle to afford. Here, where the median household income per year is $96,677 — compared to the national median of $57,617 — therapists aren’t forced to work with insurance companies, anyway; many of their clients are willing to pay.
“I’m constantly trying to battle with ‘How do I make money and sustain a living here but still feel that I’m providing for people?’” — Kealy Spring, therapist
It appears that as long as rents are pricey and salaries are top-of-range in the Bay Area, the lack of affordable therapy will persist where we live. The more some people can afford it, the less others can—a motto too common in this city.
So who are some of the people actually willing to take insurance patients? Usually, there’s some reason they’re on your insurance roster—perhaps they’re struggling to find private-pay clients for whatever reason (they’re new to the field, or they simply aren’t good), or they feel a moral imperative to take on those who can’t afford out of pocket.
“I’m constantly trying to battle with ‘How do I make money and sustain a living here but still feel that I’m providing for people?’ said Kealy Spring, a therapist with a private practice and a member of the San Francisco Chapter of the California Association of Marriage and Family Therapists. “It’s really a balance — I’m driven to help and support and want to donate time, but it’s a matter of affording it.”
Spring notes that she has to pay her private-practice rent on top of her own living expenses. She still tries to do her part in keeping several sliding-scale spots (a fee structure whereby patients pay a percentage of their income) open at her practice. She also encourages people to seek out clinical associates, who are working towards licensure and are supervised by clinicians. And start-ups in San Francisco are attempting to combat this issue, like Lyra, which works with employers to offer their employees affordable and accessible therapy (companies like eBay and Lyft offer their services, for example).
But how much of the responsibility lies with health-insurance companies to bring more providers in-network or pay them a more fair rate?
For Linden (a health advocate), the fact that these companies consistently refuse to re-examine reimbursement rates makes her think the only solution may be legal action — much like an influential physical-therapy court case in Vermont, which gave Medicare beneficiaries full coverage.
“The case wound its way up to the Supreme Court in Vermont and changed physical therapy for every Medicare beneficiary in this country,” said Linden. “It’s going to take a very well-crafted and carefully chosen lawsuit for this issue as well.”
Now that many of us, even in moments of difficulty and darkness, are ready to ask for help, why isn’t it there? San Francisco deserves better.
One way or another, something in this complicated, finance-bound system has to give. Emily Wilburn, a San Francisco resident who went through a difficult period finding a therapy through her insurance, believes this should be an issue top of mind for the city to solve.
“I do think San Francisco has to do something about the lack of available mental-health care,” Wilburn said. “We can directly see the effects of not having proper health care through the homelessness problem here. More people are battling deeper issues — and many of them are realizing the need to get help. But the available resources haven’t caught up.”
For years, the battle against getting help was a social one. Stigma prevented many from feeling comfortable (or safe) seeking therapy — and even now, we’re not out of the shadows. But now that many of us, even in moments of difficulty and darkness, are ready to ask for help, why isn’t it there? San Francisco deserves better.
*Names changed for those who wished to speak about their mental health anonymously
Hey! The Bold Italic recently launched a podcast, This Is Your Life in Silicon Valley. Check out the full season or listen to the episode below featuring Alexia Tsotsis (Former Editor-in-Chief, TechCrunch. More coming soon, so stay tuned!
