When it comes to predicting the outcome of psychological treatments, the therapeutic alliance is one of the most widely investigated variables. For example, a recent meta-analysis of 295 studies on the association between the therapeutic alliance and the overall outcome in adult psychotherapies revealed that the alliance was positively related to treatment outcome across all forms of therapies, cultural contexts, and client characteristics. Yet little research exists on how relational social and economic factors such as class affect the quality of the therapeutic relationship.
New work led by Martin Wolgast at Lund University in Sweden finds that people of lower socioeconomic status are reliably estranged from the therapeutic alliance. People from lower socioeconomic and ethnic minority backgrounds typically experience a higher number of adverse life events, more ‘generic life stressors’ of modern life (such as debt), and more significant psychological distress. Nevertheless, most therapeutic interventions have been developed to address the issues and concerns of the educated middle class, and symptom complaints are treated differently in clients of different socioeconomic statuses.
Unsurprisingly, then, Wolgast and his colleagues report that the “available research suggests that psychotherapy is not ‘class neutral,’ and that clients from working-class or lower socioeconomic positions might be systematically at a disadvantage in psychotherapeutic contexts.”
While traditional definitions of social class delineate classes based on aspects such as individuals’ relationship to the means of production and ownership of capital, a more readily measurable marker of class relations consists of quantitative differences in socioeconomic status. The researchers predicted that socioeconomic status would be positively correlated to the client’s perception of the quality of the therapeutic alliance; in other words, they predicted that participants with higher socioeconomic status (SES) would rate the therapeutic alliance as better than participants with lower SES.
The findings support this hypothesis. Using structural equation modeling of 217 respondents’ surveys, the researchers found a pattern of estrangement of lower SES clients from the therapeutic context.
The researchers explain that such estrangement from the therapeutic context “might entail both experiences in the clients of not being understood and as inferior in relation to their therapist, as well as perceptions among the therapists of working-class client[s] as being less suitable for and receptive to psychotherapy.”
These results were more substantial in clients participating in psychodynamic therapy versus cognitive behavioral therapy, perhaps due to the different roles of the psychotherapist within these treatment modalities.
These findings, the authors note, can also be understood to suggest “that there exist internalized class-based prejudices in therapists, reflecting the fact that they themselves belong to the middle class and that the therapy model they practice is based on the norms of the middle class.”
These results suggest a profound need for change in psychotherapeutic training, research, and method development.
Wolgast, M., Despotovski, D., Lachonious Olsson, J., and Wolgast, S. (2021). Socioeconomic Status and the Therapeutic Alliance: An Empirical Investigation Using Structural Equation Modeling. J Clinical Psychology, 1-16. (Link)
good information, thank you 🙂 .
my own experience has been that social class is a -huge- issue in all aspects of the mental health industry. in the talking section, one has to be “good enough” for talking treatments. “Good enough” is based on a number of predictable variables (social class, education level, age, gender, race, sexual orientation), but also on some factors that I think are harder to discern in large studies, such as…
level of vulnerability. an affluent individual who wants some sort of talking treatment, has resources and good insurance is far less vulnerable than an affluent individual with a history of…drug use, hospitalizations, labels, any criminal/legal entanglements, facing divorce, that sort of thing. basically…
my personal, limited experience has been that the talking experts will rip vulnerable people to shreds, given the chance. labels, gaslighting, over-billing, fraud, referrals to prescribers..
and the ones they cannot rip to shreds are often simply coddled and over-billed. 🙂
I think efficacy also plays a role–therapists like anyone else wants to feel that they are good at their job, so people who are extremely difficult to help (in the sense of not responding to conventional treatment) may frustrate them after time.
Which sadly becomes an excuse to blame the client. And the DSM makes client blaming easy.
“These findings, the authors note, can also be understood to suggest ‘that there exist internalized class-based prejudices in therapists ….'”
I do believe this is most likely the case, only I found them to be biased against those living a “middle class” life, too. And I noticed, from reading my medical records, that at least one psychiatrist illegally nosed into my private finances, and declared me to be “unemployed.”
When in reality I was a “super mom” in my neighborhood, a planning commissioner of my village, I was a co-chair of a 250 volunteer strong school art program, functioning as the Charter Rep for my local Boy Scout pack, helping with the Girl Scouts, as well as volunteering to do many, many other school and church activities, while I was also working on my art portfolio, and of course raising my children. “Living the dream,” as some of my neighbors called it.
What do you think was the likelihood that I told that criminal psychiatrist I was “unemployed”? Zero. And, in case you doubt that psychiatrist was a criminal, here is her partner-in-crimes’ US justice department’s conviction announcement.
I’m quite certain the quality of the “mental health” industries would be much higher, if they actually listened to, and believed, those they claim to be “helping.” Rather than getting lies and gossip from pedophiles, making mis-informed assumptions, and taking illegal shortcuts – as my medical records show were the sources of my psychologists’ and psychiatrists’ misinformation about me.
And I will say, as soon as my other former psychiatrist finally bothered to look at my art work, he called it “insightful, “work of smart female,” and he weaned me off his neurotoxins.
Then years later, another psychologist, after seeing a show of my work, nosed into my personal finances, and he wanted to become my “art manager.” He claimed because “the world might be ready for a Chicago Chagall,” which is a simplistic description of some of my work. But since his “art manager” contract was just a thievery / conservatorship contract, I declined his appallingly persistent demands to sign his contract.
Anyone else here find that some working within the “mental health” field have a problem understanding words like “No thank you,” “Your drugs make me sick,” and “It’s against my religion to take your drugs”? I literally had to ask a bunch of “mental health” workers once, “Does anyone here speak English?”
I agree, there is “a profound need for change in psychotherapeutic training, research, and method development.” There is also a profound need for an improvement in the psychological industry’s ethics.
We do also need an end to the medical/religious “conspiracy” against child abuse survivors, and their legitimately concerned family members, which was confessed to me to be “the dirty little secret of the two original educated professions.”
There is also a profound need for the “mental health” industries – particularly the systemic, child abuse covering up psychological industry – to garner insight into the concept of “Live, and let live.”
There is also a profound need for people to garner insight into the fact that covering up child abuse is still technically illegal behavior in America. And that slice of wisdom does go out to the psychological, psychiatric, and religious industries – not to mention, apparently also the US government, and globalist “elite.”
I am often a bit surprised with this narrative about “class” in psychotherapy.
IMHO, psychotherapy seems to me is for certain class. If we are talking about “talk therapy”, it is mainly for middle or upper class. I do not know many people who can easily afford psychologist or psychotherapist charging enormous amount unless they are in jail and or mandated.
So who are these “poor” utilizing psychotherapy that are often being looked down on. I can see medicalizing but not so much talk therapy.
I only see in articles and do not know many poor people having talk therapy and I have been involved in poorer communities for many years.
They cannt even afford and that is the biggest problem.
They might be talking more about social workers, or people who go to low-cost clinics or those who have to see graduate students doing their hours for licensure under supervision.
I think one of the points is that the way talk therapy is designed is inherently poorly-fitting with “lower” class norms/ways of being/doing/relating/etc.
Good article but I wish it had been fleshed out a little more, for example are there other forms of therapy beyond psychodynamic and CBT and how do they fare with varying SES-based demographics? (Especially things like family and/or group therapy.)
Also I think sociologists usually use four different variables to calculate SES (iirc it’s level of education, income, wealth and occupation [e.g., blue- vs. white-collar]).