Lisbet wondered if the victim advocate had made a mistake. Lisbet was at the Family Justice Center in San Diego, a social services agency for domestic violence survivors, trying to get help with basic needs like shelter and food after leaving her abusive husband. And she was being offered counseling.
“I was like, ‘Oh my gosh, why do I need therapy? Do they think I’m crazy?’” recalled Lisbet, who asked that her last name not be used to protect her children’s safety. “I couldn’t understand at that moment how important it is to seek therapy after overcoming a traumatic situation.”
While it came as a surprise to Lisbet, domestic violence survivors often need mental health care. Like veterans of wars or victims of human trafficking, these survivors have often been subjected to prolonged periods of extreme stress and fear for their safety, which is harmful to the health of both body and brain. And the need is widespread: An estimated 1 in 4 women and 1 in 7 men in the United States experience severe physical violence at the hand of an intimate partner in their lifetime.
Californians in general struggle to find and afford mental health treatment, but the access difficulties are magnified for survivors. These access challenges are often compounded by practical, cultural and linguistic barriers including — as in Lisbet’s case — the overwhelming nature of domestic violence, health insurance limitations, stigma and fear of turning to authorities for help.
Experts who spoke with the California Health Report said the state should do more to help domestic violence survivors and their children access mental health support by providing additional funding to domestic violence agencies to expand mental health services, requiring insurers to better cover mental health care and reimburse providers fairly, and by incentivizing more people to enter behavioral health professions. Some advocates and survivors also called for reimagining criminal justice and child welfare responses to domestic violence to reduce the risk of penalizing or alienating victims.
‘No space for caring for yourself’
In the seven years prior to leaving her husband, Lisbet’s focus had been on surviving. She walked on eggshells, trying not to do or say anything that might throw him into a rage, trying to keep herself and her three kids safe. She ignored her health: the nagging muscle aches, her inability to sleep, the overwhelming stress that — after one particularly bad argument — sent her body into temporary paralysis.
An undocumented immigrant, Lisbet lived in fear that she’d get deported or lose her children if she told an authority — even a medical professional — about the abuse. She had no health insurance to see a doctor anyway. And mental health care? Talking about mental health was considered shameful in her family.
“When you’re in (a domestic violence) situation, there’s no space for caring for yourself,” Lisbet said. “For me it was like, ‘Oh, I’m tired, I’m under a lot of stress, it’s normal.’”
People in abusive relationships are often under incredible stress, and their partners may control their access to health care, making it difficult for them to seek help. One study of California residents found that adult survivors of intimate partner violence were 3 times more likely than non-survivors to report serious psychological distress. Survivors’ children are also at heightened risk for mental health challenges, including post-traumatic stress disorder and difficulty regulating emotions, even if they witness the abuse and don’t experience the violence directly, studies show.
More than a third of Californians are insured under the state’s Medicaid program, known as Medi-Cal, and they often struggle to find therapists willing to take that insurance due to low reimbursement rates compared to private insurance or out-of-pocket pay. About 3 million Californians, many of them undocumented immigrants, have no health insurance and most of them cannot afford to pay for mental health care in cash. For survivors who speak languages other than English, finding therapists who speak their language and understand their cultural background can be especially hard.
Seeking mental health care can also come with risks. Disclosing domestic violence to a medical professional (who under California law must report potential child mistreatment) can end up triggering the involvement of child protective services and the removal of children, whether or not it’s justified. The exposure of children to violence in the home, even if they don’t witness it directly, is considered child abuse, which mental health practitioners are required to report to CPS. This is particularly concerning for many survivors of color, whose children are overrepresented in California’s foster care system.
‘Afraid to call the police’
Communities of color often experience negative consequences from police or social service involvement, such as family separation and incarceration. Black and indigenous children, for example, end up disproportionately in California’s foster care system, and Black and Latinx Californians also face higher incarceration rates due to a legacy of racism in the criminal justice system and larger society. Given these realities, Charmine Davis, director of family wellness at the Jenesse Center, a domestic violence intervention and prevention program in Los Angeles, said many survivors of color are understandably afraid to seek help.
“You have these survivors or victims who are afraid of the system, they’re afraid to call the police, they’re afraid to go to the doctor, they’re afraid social services is going to be called,” Davis said. “I’ve seen grave consequences … By the time they get to us they can be so depressed they’re ready to commit suicide. They are so depressed they’ve lost touch with reality.”
To encourage more survivors of color to seek help sooner, California needs to work on building access to culturally competent and sensitive mental health services, staffed by professionals who understand and look like the people they are serving, Davis said. California has a shortage of mental health professionals in general, but that shortage is particularly acute when it comes to professionals of color. Latinos constitute 38 percent of California’s population, yet only 4 percent of psychiatrists, 8 percent of psychologists, and 23 percent of counselors, according to research by UC San Francisco. Likewise, African-Americans make up 6 percent of California’s population, but just 2 percent of psychiatrists (although they are more evenly represented among the ranks of counselors and social workers, the study found).
Davis said she believes the mandatory reporting law for medical professionals should also be changed so that patients feel more comfortable disclosing information about domestic violence. She also pointed to what she sees as unreasonable requirements for many survivors whose children are removed — including being forced to travel long distances to see their kids while also complying with random drug tests, all of which adds stress to an already difficult situation and makes it harder for them to recover. These compliance requirements to regain custody of children need to be overhauled, Davis said.
“In the Black community, a lot of women aren’t treated fairly,” she said. “This community is hurting.”
A lifeline for mental health support
Organizations like the Jenesse Center that specialize in providing shelter, legal and other support to domestic violence survivors have become a vital entry point for mental health services. These agencies specialize in working with survivors and their children and are experienced at building trust with wary clients, advocating for them and recognizing signs of trauma.
Over the past five years, with California’s mental health system stretched thin and demand for mental health care growing, more and more domestic violence agencies have set up their own mental health teams, said Jasmeen Kairam, a project manager at the California Partnership to End Domestic Violence, which provides technical support to agencies across the state. These teams are often staffed at least partially by therapy and social work interns completing licensing requirements, which helps keep the cost of providing care lower than hiring fully licensed clinicians.
At WEAVE, a crisis intervention agency for domestic violence and sexual assault survivors in Sacramento, survivors and their family members can get approximately 8 individual therapy sessions and 15 weeks of group therapy for free. The agency, supported by government and private grants along with revenue from three retail stores, also offers some longer-term therapy on a sliding scale for as low as $35 as hour, although even this amount can be challenging for people with very low incomes. Advocates can also help survivors apply for additional mental health coverage through the California Victim Compensation Board, a state agency that reimburses crime-related expenses for survivors of violence, including domestic violence. The challenge is that many survivors are intimidated by the paperwork required to obtain this compensation and decide not to apply, said Jaime Gerigk, WEAVE’s head of counseling and outreach. Some providers have also criticized the program for being mired in red tape, making it difficult for them to serve survivors.
Meanwhile, some smaller domestic violence organizations that don’t have the means to hire clinicians themselves have found ways to partner with other nonprofit, health or social service agencies to obtain mental health support for their clients. The Family Assistance Program based in Victorville, for example, partners with the San Bernardino County Public Health department to ensure clients that enter the organization’s domestic violence shelter receive mental health support within 48 hours, said Program Manager Jobi Wood. The program also hires a health advocate whose job is to develop relationships with mental health providers in the community, understand how to navigate insurance, and advocate for clients so they can get the care they need.
Yet while domestic violence organizations play an important role in helping survivors and their children obtain needed mental health care, there are limits to what they can provide. Demand for therapy often outstrips supply. Funding constraints limit support to short-term intervention rather than the long-term care some survivors need for recovery.
At WEAVE, for example, survivors might have to wait a month or two to see a therapist, increasing the risk that their symptoms could worsen, or that they might give up on seeking help and return to an abusive partner, Gerigk said.
“When someone reaches out for counseling, they’re wanting it right then, it takes a lot of courage to reach out and say I want to talk to a therapist or a counselor,” she said. “For me to have to say, well, it’s going to be about eight, 10, 12 weeks, you know, I wish I didn’t have to do that.”
Forced to limit patients to pay bills
Close to two-thirds of adult Californians with a mental illness don’t get treatment. Common reasons cited are cost and not knowing how to get it. Provider shortages likely add to the problem given that California’s mental health care workforce meets only about a quarter of actual need, according to data compiled by the Kaiser Family Foundation. The deficit is expected to intensify over the next decade as large numbers of behavioral health professionals reach retirement age.
Without workers, no amount of funding or tweaking mental health policies will be enough, said Vickie Mays, a psychology professor and director of the BRITE Center for Science, Research, and Policy at UCLA. She said the state and federal government need to increase mental health training programs and encourage more students to enter the field.
“The need has outstepped the capacity to provide that care,” she said. “We just don’t have the workforce currently that we need, and we’ve got to start thinking about alternative ways to meet these needs.”
Other barriers to care are low rates of insurance acceptance among mental health providers. Many mental health care providers in private practice have stopped taking insurance, or reduced the number of insured clients they’ll see, citing low reimbursement rates and frustrating bureaucratic procedures. A 2021 survey by the American Psychological Association found that 81 percent of psychologists nationwide accepted self-paying clients, but just 66 percent accepted private insurance and only 31 percent accepted clients with Medicaid.
Cathia Walters, a licensed clinical psychologist in private practice who works with survivors of intimate partner violence, particularly survivors of color, said she has to limit the number of Medi-Cal recipients she accepts in order to survive financially, even though she would like to accept more. Even commercial insurance plans pay far less than the $200 or more she could charge per hour privately, Walters said, but she mostly accepts clients with insurance because she wants to serve the people who most need her help.
“I didn’t go into (this work) for the money, but I have bills to pay,” she said. “Trying to get these insurances to raise the rates is a battle. Honestly I’ve dropped some insurance because I still have to live.”
Patients who can afford to pay for mental health care out of pocket are increasingly doing so.
The result is a tiered system for mental health care. Californians who can afford to pay out of pocket have an easier time finding a provider, while those with private insurance or Medi-Cal compete for the remaining pool of providers willing or available to accept their insurance.
For patients insured under Medi-Cal or without insurance it is often possible to find care at federally qualified health centers, community mental health centers, or through a community-based organization such as a domestic violence agency. But these options can come with long wait times, fewer or less frequent appointments than a patient would like, and providers are sometimes less experienced than those in private practice.
Some survivors struggle to get any help at all. Anneliese Waters, 44, of Los Angeles said she left multiple voicemail messages with domestic violence agencies in her area after escaping an abusive marriage in another state, but never got a call back. Both she and her oldest daughter needed counseling, she said. Desperate, she scrounged together enough money to pay out of pocket for her daughter to see a therapist but was never able to afford one for herself. She ultimately started her own support group and is now studying for a doctorate in social work and hopes to open a nonprofit to help other survivors.
“To not get a response was very crushing, it made me very sad and angry,” she said. “It just fired me up to want to be able to do something in the long run.”
Mental health care seen as secondary
Psychologist Amber Deneén Gray, founder of Gray’s Trauma-Informed Care Services Corp., which trains a wide range of professionals on how to work with and advocate for domestic violence survivors, said a big obstacle is that mental health care is often regarded as secondary to other needs such as care for physical injuries, legal help, and shelter. Government and private funding for domestic violence services usually prioritizes the latter, she said. Insurance companies cover medical care for someone who’s been beaten or shot by an intimate partner, but often quibble at authorizing more than a few therapy sessions, she added.
In recent years, both California and the federal government have pushed insurers to cover medical and mental health care equally — a concept known as mental health parity. Gov. Gavin Newsom and state legislators has also enacted or proposed various boosts and changes to mental health funding, and new rules aimed at streamlining or facilitating care.
The Newsom administration has allocated $4.7 billion to a 5-year Children and Youth Behavioral Health Initiative that seeks to vastly increase access to mental health and substance use treatment for children and young people. Strategies include increasing the number of school counselors, training thousands more mental health workers, and making family therapy more accessible through Medi-Cal. Family therapy can be particularly important for addressing the mental health effects of intimate partner violence on children.
But the reality is that for many Californians, obtaining mental health treatment remains more difficult than getting care for physical ailments. Evidence of this was on full display last August when 2,000 Kaiser Permanente mental health care clinicians went on strike for weeks, alleging staff shortages, unsafe therapist-to-client ratios and patients waiting as long as three months to get an appointment with a therapist. This despite a 2021 California law that requires health insurers to limit wait times for mental health care to no more than 10 business days. California health plans also regularly deny patients medically necessary mental health treatment, and advocates contend that plans are skirting mandates to provide mental health coverage on the same terms as they do for physical health conditions.
“In the nearly 30 years I’ve worked in this field, (survivors) get mental health services, but not the ideal,” said Gray, who believes most survivors should get at least a year of therapy. “There is money for it, but it’s not prioritized.”
For Lisbet, access to mental health treatment and other help opened up after she worked up the courage to report the abuse to police. Instead of getting deported or losing her children, as she had feared, they directed her to the San Diego Family Justice Center, now called Your Safe Place, A San Diego Family Justice Center, a multi-agency service center for victims of domestic violence and other forms of abuse, overseen by San Diego County’s District Attorney’s Office.
At first, Lisbet agreed only to attend group support sessions, and accepted individual counseling for her son who was showing signs of trauma. As she became more comfortable with the idea, she began individual counseling for herself, and later saw a psychiatrist who prescribed medications to help her with depression. Today, rather than seeing mental health treatment as a weakness, Lisbet regards it as critical to her recovery and an important tool for self-care. She continues to receive counseling, is an advocate for domestic violence survivors, and facilitates a support group for Spanish speakers.
“I want to use my experience to raise more awareness about mental health for individuals who go through intimate partner violence,” especially in the immigrant community, she said. “We need to do a better job of … educating our community about the impact, the trauma that comes along with being in those abusive situations, and that it’s normal, it’s OK to ask for help.”
Domestic Violence support:
If you or someone you know is experiencing domestic violence, contact the National Domestic Violence Hotline at 1-800-799-7233 for support and referrals, or text “START” to 88788. You can also find contact information for your local domestic violence program using this online tool.
For Native Americans and Alaska Natives, the StrongHearts Native Helpline at 1-844-7NATIVE (762-8483) also provides 24/7 confidential and culturally appropriate support and advocacy for survivors of domestic and sexual violence. A chat option is available through their website.
For information about financial assistance for victims of crime, including for survivors of domestic violence, visit the California Victim Compensation Board at https://victims.ca.gov
Mental Health support:
If you or someone you know are experiencing a mental health crisis, call or text 988 to reach California’s Suicide Prevention and Mental Health Crisis Lifeline.
The California Health Report is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center’s Rosalynn Carter Fellowships for Mental Health Journalism, the Center for Public Integrity , and newsrooms in select states across the country.