My friend who struggles with mental health can’t afford to get support, what can I do?

1) Dear Alice! 

I have a close friend who has a number of rather difficult issues. One of the most important is a long history of abuse (largely psychological) from her mother during her childhood. (She is now 19.) It is incredibly difficult to talk to her about any of these things. I would like her to see Psych Services, but I am worried about the fact that there are only a limited number of sessions available — that is actually one of the reasons she has offered to me as to why it would be a waste of time to go. Unfortunately, the only medical coverage she has is through her mother's medical insurance, she has no real money outside of her parent's control — it would be extremely difficult for her to pay for counseling, in other words, without alerting her parents. What can she do? What can I do?

2) Dear Alice,

I am actually asking for a friend of mine since this situation is getting worse, and I don't know how to help. The problem is that my friend is very depressed, and has very, very low self-esteem. While sometimes able to be cheerful and "happy," he claims to rarely feel that way and mostly just hates himself. He has mentioned suicide, although I think this is more an expression of the extreme self-hatred he feels than anything. I comfort him and often tell him how wonderful he is — what a good person, good qualities, etc., but I suspect he does not believe me at all. This has been going on for a long time now, and I think it stems from a somewhat unhappy childhood and adolescence. I don't know how to help him and I don't know what to do. I feel like being strong for him is just not enough, and I can't quite convince him that counseling may do some good. It seems to me that, recently, he has been feeling even worse about himself, to the point where nothing will comfort him. He cannot afford counseling, and he has no health insurance. Is there anything you can suggest for me to tell him or suggest to him? Any help will be greatly appreciated, because I just don't how to help him. Thank you so much.

— A friend on-the-line

Health topics
Mental and Emotional Health
Blues and Depression
Personal and Peer Support
Answer

Dear Reader and A friend on-the-line, 

You’ve both done a lot to show you care for your friends who you’ve noticed are struggling. Even if they’re currently unreceptive to help, being there for them can go a long way in helping them work through challenges and feel supported. Since both of your friends experienced struggles as children, it’s possible that adverse childhood experiences (ACEs) are related to the poor mental health or depressive symptoms they’re experiencing now. Reader, you mentioned your friend being on her mother’s insurance, and A friend on-the-line, you mentioned your friend not having insurance at all. No matter their current coverage status, there may be free, sliding scale, or reduced cost options for mental health support should your friends choose to seek help from a mental health professional. 

In addition to ACEs, some possible causes of poor mental health are traumatic events, genetic factors, family history of mental health challenges, and substance use, though this list isn’t exhaustive. It’s important to note that people who are experiencing mental health challenges often find it difficult to recognize and admit to themselves or others that they’re struggling. Signs of a mental health struggle can vary from person to person, but in the case of depressive symptoms, common patterns include: 

  • Losing interest in activities they once enjoyed 
  • Unexplainable physical pain 
  • Feeling worthless or guilty and fixating on past mistakes 
  • Problems with concentration 
  • Suicidal ideation or mentioning not wanting to be alive 

Many people experience negative feelings, however, when these feelings become extreme, prolonged, or disrupt functions of daily life, it could be an indication that a more serious problem is going on. You both seem to have noticed similar situations with your friends and maybe aren’t sure how to bring it up with them. If there’s an immediate emergency, it might be helpful to contact a crisis hotline. In other cases, some conversation starters to try might include: 

  • I've been worried about you. Would you feel comfortable talking to me about what you’re experiencing? If not, is there someone else you’d feel more comfortable talking to? 
  • I’m someone who cares and wants to listen. Is there some way I can support you through these feelings? 
  • It seems like you’re going through a difficult time. How can I help you to find help or support? 
  • Sometimes speaking with someone who shares or has dealt with a similar experience helps. Do you know of others who have experienced these types of problems who you can talk with? 
  • I'm concerned about your safety. Have you thought about harming yourself or others? 
  • I’m here to listen if ever want to talk. 

List adapted from the Substance Abuse and Mental Health Services Administration 

While these prompts may help to open the door to a conversation, it’s also possible they may not want to talk about it. In which case, it’s best not to push them as it may cause them to isolate further. Other things you may choose to try are inviting and including them in activities (even if they decline), helping them with their tasks, and treating them with compassion. There are also Mental Health First Aid courses you may choose to look into to help educate yourself about mental health more broadly. Doing these things may help to show your friends that you’ll support them no matter what they’re going through. 

If these friends do become interested in seeking help from a mental health professional, there are options for people with and without health insurance, and services that are willing to work with a client's income level. For free or pay-what-you-can services, you might suggest that your friends reach out to a federally funded health center or use the treatment facility locator from the Substance Abuse and Mental Health Services Administration as a starting point. Free hotlines like the 988 Suicide and Crisis Lifeline or National Helpline (1-800-662-HELP) are confidential numbers they may call for help or treatment information. For services with sliding-scale costs, the Anxiety and Depression Association of America has a resource to link people to nearby therapists to avoid a potentially long wait time or limited number of sessions. If your friends are students, their college campus may also have free or low-cost therapy, in either individual or group sessions. There are also mental health apps to guide people through their thoughts and emotions. 

It’s great that you’re thinking of your friends in their trying times. Whether they can’t afford services or aren’t ready to seek help from a mental health professional, being there for them is also a form of support. Staying educated on mental health challenges and knowing what resources are available shows that you’re receptive to their struggles and ready to help them if they want it in the future. 

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Summary of informative links

Summary

Source 1: What is Mental Health? For Friends and Family Members

  • This source has information on how to support a loved one who is experiencing a mental health problem and provides some examples of how to approach a conversation about it. There are also resources for finding a provider or reaching out to a helpline.

Source 2: Patterns of adverse childhood experiences and depressive symptoms: self-esteem as a mediating mechanism

  • Introduction: Adverse childhood experiences (ACEs) often occur in tandem with each other and are associated with a plethora of adverse outcomes in adulthood. These include but are not limited to low self-esteem, homelessness, substance use or abuse, violence, suicide or suicidal ideation, depression, anxiety, and other mental health problems.  
  • Purpose/Method: figure out patterns of ACEs and examine the causal pathway between ACEs, self-esteem, and depressive symptoms. Hypothesis: ACEs differ with respect to self-esteem and depressive symptoms, and self-esteem is a mediator of the ACEs-depressive symptoms relationship. Final dataset included 10,784 participants from 3 waves of the National Longitudinal Study of Adolescent and Adult Health.
  • Results/Discussion: 4 groups of ACEs identified, among them Child Maltreatment. This group had the largest association with depressive symptoms and was mediated by self-esteem. Other variables like gender, race, and education were also correlated with depressive symptoms.  

Source 3: Depression: Supporting a family member or friend

  • This source specifically discusses signs of depression and how to approach a loved one who may be experiencing depression. It emphasizes that depression occurs when depressive symptoms interfere with daily functioning or social relationships and that many people refuse to admit or confront that they have depression. Warning signs and methods to support a person with depression are described, and a section about signs of suicidal risk is provided. Being present for someone, being patient, and being open to listening are some methods for support.  

Source 4: Low-cost Treatment

  • The Anxiety & Depression Association of America provides a fact sheet on options for therapy or medication for mental health issues. Listed are therapists with sliding scales for payment, federally funded health centers, college/university services, patient-assistance programs from drug companies, participating in clinical trials, or telehealth or use of apps.  

Source 5: What is Mental Health First Aid?

  • Mental Health First Aid (MHFA) is a program under the National Council for Mental Wellbeing that provides courses training people to respond to mental health or substance abuse challenges. Some topics covered include how to recognize signs of crisis, how to help people through crisis, and how to connect them to help. Local courses are available in person or online across the United States.

Overall conclusions

  • The response should be fairly straightforward, as there are a plethora of sources about how to support someone who is or may be going through a mental health crisis. Emphasize that it might be difficult for the person to hear it or want to get help, and that money is a huge factor, but there are low cost and free options available if they want it.

Proposed outline

  1. Commend the askers for wanting to help their friends and for noticing that they may be struggling. Note that adverse childhood experiences are linked to depressive symptoms and that ACEs often occur together so their observation has some actual evidence (Source 2). Mention that even if the friend is on someone else’s insurance where it might be hard to seek psych services or if they don’t have insurance, there are free or reduced cost options for therapy should they choose to seek it.
  2. Signs and symptoms of mental health challenges and some possible causes of poor mental health (ACEs, other traumatic events, genetic component, family history of mental illness etc). Difference between sometimes feeling down or depressed and when it may be more serious, including discussion of suicide or suicidal thoughts. (sources 1- 3)
  3. How to support a friend going through mental health challenges, how to start a conversation about it, and next steps (source 1 and 3)
  4. Resources for helping them find help, either through looking for therapists, going to a community clinic, campus clinic, calling a hotline, etc. (sources 4 and 5)
  5. Reassert that it is great they are thinking of their friend, and there are a variety of ways to get them help if they are open to it. If not, being there for them is still a way to support them through what they are experiencing

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