Barriers to Mental Health Care for Low-Income Clients As Perceived By Counsellors
DOI:
https://doi.org/10.33043/r23873x5Keywords:
low income, Barriers, Challenges, Concept Mapping, CounsellingAbstract
This study aimed to answer the question, “What have [counselors] found to be the least helpful aspects of counseling with clients facing low income?” One hundred thirteen counselors were recruited via mass email, completed an online survey, and participated in individual interviews. Using a group concept mapping procedure, participants grouped the data into seven concepts, including barriers due to low income and employment, systemic barriers for clients, obstacles due to trauma, competing needs and priorities, biased approaches, limits to real-world helpfulness of counseling, and negative impacts of systems on and for counselors. The results highlight the importance of identifying and addressing inequities faced by clients living with a low income to increase the accessibility and availability of mental health services for all.
Downloads
References
Abdel-Rahman, S., Awwad, F. A., Ismail, E. A. A., Kibria, B. M. G., & Abonazel, M. R. (2023). Predictors of mental health problems during the Covid-19 outbreak in Egypt in 2021. Frontiers in Public Health, 11, Article 1234201. https://doi.org/10.3389/fpubh.2023.1234201
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., Bromet, E., Bruffaerts, R., de Girolamo, G., de Graaf, R., Florescu, S., Gureje, O., Hinkov, H. R., Hu, C., Huang, Y., Hwang, I., Jin, R., Karam, E. G., Kovess-Masfety, V., . . . & Kessler, R. C. (2014). Barriers to mental health treatment: Results from the WHO World Mental Health surveys. Psychological Medicine, 44(6), 1303–1317. https://doi.org/10.1017/S0033291713001943
Appio, L. (2012). Class-related experiences of poor and working-class clients in therapy with class-privileged therapists [Unpublished manuscript]. Teacher’s College Press, Columbia University.
Appio, L., Chambers, D.-A., & Mao, S. (2013). Listening to the voices of the poor and disrupting the silence about class issues in psychotherapy. Journal of Clinical Psychology, 69(2), 152–161. https://doi.org/10.1002/jclp.21954
Aslan, H., & Padir, M. A. (2023). Does school counselors’ self-efficacy to work with gifted students fed by their knowledge and perception regarding giftedness. Research on Education and Psychology, 7(Special Issue 2), 625–639. https://doi.org/10.54535/rep.1363878
Ballo, E., & Tribe, R. (2023). Therapeutic work with clients living in poverty. The International Journal of Social Psychiatry, 69(4), 1043–1050. https://doi.org/10.1177/00207640221139798
Balmforth, J. (2009). ‘The weight of class’: Clients’ experiences of how perceived differences in social class between counsellor and client affect the therapeutic relationship. British Journal of Guidance and Counselling, 37(3), 375–386. https://doi.org/10.1080/03069880902956942
Baum, A., Garofalo, J. P., & Yali, A. M. (1999). Socioeconomic status and chronic stress. Does stress account for SES effects on health? Annals of the New York Academy of Sciences, 896(1), 131–144. https://doi.org/10.1111/j.1749-6632.1999.tb08111.x
Bellerose, M., Rodriguez, M., & Vivier, P. M. (2022). A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women. Health Services Research, 57(4), 775–785. https://doi.org/10.1111/1475-6773.14008
Bhattacharyya, S., Kaur, J., Corpus, G., Lykes, M. B., & Heesacker, M. (2018). ‘There Are Many Social Evils . . . And Only We Can Cure It’: A thematic content analysis of privileged Indian youth’s perspective on social issues. Journal for Social Action in Counseling and Psychology, 10(1), 2–23. https://doi.org/10.33043/JSACP.10.1.2-23
Borges, A. M., & Goodman, L. A. (2020). Considering poverty in the therapeutic process: Experienced therapists’ adaptations. Counselling Psychology Quarterly, 33(4), 490–515. https://doi.org/10.1080/09515070.2019.1589420
Bradley-Davino, B., & Ruglass, L. (2008). Trauma and posttraumatic stress disorder in economically disadvantaged populations. American Psychological Association, Division, 56. https://apatraumadivision.org/wp-content/uploads/2023/11/economically-disadvantaged.pdf
Brown, J., Wiendels, S., & Eyre, V. (2019). Social justice competencies for counseling and psychotherapy: Perceptions of experienced practitioners and implications for contemporary practice. Counselling and Psychotherapy Research, 19(4), 533–543. https://doi.org/10.1002/capr.12247
Burgos, M., Al-Adeimi, M., & Brown, J. (2019). Needs of newcomer youth. Child and Adolescent Social Work Journal, 36(4), 429–437. https://doi.org/10.1007/s10560-018-0571-3.
Chalifoux, B. (1996). Speaking up: White, working-class women in therapy. Women and Therapy, 18(3–4), 25–34. https://doi.org/10.1300/J015v18n03_04
Chen, J. A., Olin, C. C., Stirman, S. W., & Kaysen, D. (2017). The role of context in the implementation of trauma- focused treatments: Effectiveness research and implementation in higher and lower income settings. Current Opinion in Psychology, 14, 61–66. https://doi.org/10.1016/j.copsyc.2016.11.007
Clark, M., Moe, J., Chan, C. D., Best, M. D., & Mallow, L. M. (2022). Social justice outcomes and professional Counseling: An 11‐year content analysis. Journal of Counseling and Development, 100(3), 284–295. https://doi.org/10.1002/jcad.12427
Collins, L., & Barnes, S. L. (2014). Observing privilege: Examining race, class, and gender in health and human service organizations. Journal for Social Action in Counseling and Psychology, 6(1), 61–83. https://doi.org/10.33043/JSACP.6.1.61-83
Cook, K., & Bergeron, K. (2019). Using Group concept mapping to engage a hard-to-reach population in research: Young adults with life-limiting conditions [International journal]. International Journal of Qualitative Methods, 18, 1-8. https://doi.org/10.1177/1609406919891315
Dare, L., & Nowicki, E. (2019). Engaging children and youth in research and evaluation using group concept mapping. Evaluation and Program Planning, 76, Article 101680. https://doi.org/10.1016/j.evalprogplan.2019.101680
Dougall, J. L., & Schwartz, R. C. (2011). The influence of client socioeconomic status on psychotherapists’ attributional biases and countertransference reactions. American Journal of Psychotherapy, 65(3), 249–265. https://doi.org/10.1176/appi.psychotherapy.2011.65.3.249
Edwin, M., & Fisher, J. (2023). School counselors’ experience and self-efficacy in providing career counseling to high-ability visual artists. Professional School Counseling, 27(1). https://doi.org/10.1177/2156759X231165495
Ettman, C. K., Abdalla, S. M., Cohen, G. H., Sampson, L., Vivier, P. M., & Galea, S. (2020). Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of us adults. Journal of Epidemiology and Community Health, 75(6), Article jech-2020-215213. https://doi.org/10.1136/jech-2020-215213
Fullen, M. C., Dolbin‐MacNab, M. L., Wiley, J. D., Brossoie, N., & Lawson, G. (2022). The impact of excluded providers on Medicare beneficiaries’ mental health care. Journal of Counseling and Development, 100(2), 123–133. https://doi.org/10.1002/jcad.12409
Gerstein, L. H., & Rami, F. (2022). International psychology and the COVID-19 pandemic. International Perspectives in Psychology, 11(3), 137–140. https://doi.org/10.1027/2157-3891/a000056
Government of Canada. (2021). The 2021 report of the National Advisory Council on Poverty. Author.
Griffin, D., & Stern, S. (2011). A Social Justice Approach to school counseling. Journal for Social Action in Counseling and Psychology, 3(1), 74–85. https://doi.org/10.33043/JSACP.3.1.74-85
Guerin, R. J., Barile, J. P., Thompson, W. W., McKnight-Eily, L., & Okun, A. H. (2021). Investigating the impact of job loss and decreased work hours on physical and mental health outcomes among US adults during the COVID-19 pandemic. Journal of Occupational and Environmental Medicine, 63(9), e571–e579. https://doi.org/10.1097/JOM.0000000000002288
Hall, L. R., Sanchez, K., Da Graca, B., Bennett, M. M., Powers, M., & Warren, A. M. (2022). Income differences and COVID-19: Impact on daily life and mental health. Population Health Management, 25(3), 384–391. https://doi.org/10.1089/pop.2021.0214
Jang, H., Choi, J., & Kim, I. (2023). Standing with Asian clients affected by the pandemic: Counseling recommendations through the MSJCC framework. Journal of Counselor Preparation and Supervision, 17(4), 3. https://research.library.kutztown.edu/jcps/vol17/iss4/3
Jansson, B. S. (2011). Improving healthcare through advocacy: A guide for the health and helping professions. John Wiley & Sons.
Jefferson, D. J., & Harkins, D. A. (2011). ‘Hey, I’ve Got a Voice Too!’ Narratives of adversity, growth and empowerment. Journal for Social Action in Counseling and Psychology, 3(2), 104–128. https://doi.org/10.33043/JSACP.3.2.104-128
Juntunen, C. L., Pietrantonio, K. R., Hirsch, J. K., Greig, A., Thompson, M. N., Ross, D. E., & Peterman, A. H. (2022). Guidelines for psychological practice for people with low-income and economic marginalization: Executive summary. The American Psychologist, 77(2), 291–303. https://doi.org/10.1037/amp0000826
Kane, M., & Trochim, W. (2007). Concept mapping analysis. In L. Bickman & D. Rog (Eds.), Concept mapping for planning and evaluation (50) (pp. 87–110). Sage Publications, Inc.. https://doi.org/10.4135/9781412983730.n5
Kaniuka, A. R., Cramer, R. J., Wilsey, C. N., Langhinrichsen‐Rohling, J., Mennicke, A., Patton, A., Zarwell, M., McLean, C. P., Harris, Y.-J., Sullivan, S., & Gray, G. (2021). COVID-19 exposure, stress, and mental health outcomes: Results from a needs assessment among low income adults in central North Carolina. Frontiers in Psychiatry, 12, Article 790468. https://doi.org/10.3389/fpsyt.2021.790468
Kim, S., & Cardemil, E. (2012). Effective psychotherapy with low-income clients: The importance of attending to social class. Journal of Contemporary Psychotherapy, 42(1), 27–35. https://doi.org/10.1007/s10879-011-9194-0
Knudsen, H. K., & Studts, J. L. (2010). The implementation of tobacco-related brief interventions in substance abuse treatment: A national study of counselors. Journal of Substance Abuse Treatment, 38(3), 212–219. https://doi.org/10.1016/j.jsat.2009.12.002
Kola, L., Kohrt, B. A., Hanlon, C., Naslund, J. A., Sikander, S., Balaji, M., Benjet, C., Cheung, E. Y. L., Eaton, J., Gonsalves, P., Hailemariam, M., Luitel, N. P., Machado, D. B., Misganaw, E., Omigbodun, O., Roberts, T., Salisbury, T. T., Shidhaye, R., Sunkel, C., . . . Patel, V. (2021). COVID-19 mental health impact and responses in low-income and middle-income countries: Reimagining global mental health. T. and T. The Lancet. Psychiatry, 8(6), 535–550. https://doi.org/10.1016/S2215-0366(21)00025-0
Lavell, E. F. (2014). Beyond charity: Social class and classism in counselling. Canadian Journal of Counselling and Psychotherapy, 48(3), 231-250. https://journalhosting.ucalgary.ca/index.php/rcc/article/download/60986/46289
Lewis, J. A., Williams, M. G., Peppers, E. J., & Gadson, C. A. (2017). Applying intersectionality to explore the relations between gendered racism and health among Black women. Journal of Counseling Psychology, 64(5), 475–486. https://doi.org/10.1037/cou0000231
Lewis, K. J. S., Lewis, C., Roberts, A., Richards, N. A., Evison, C., Pearce, H. A., Lloyd, K., Meudell, A., Edwards, B. M., Robinson, C. A., Poole, R., John, A., Bisson, J. I., & Jones, I. (2022). The effect of the Covid-19 pandemic on mental health in individuals with pre-existing mental illness. BJPsych Open, 8(2), e59. https://doi.org/10.1192/bjo.2022.25
Lewy, C. S., Oliver, C. M., & McFarland, B. H. (2014). Barriers to mental health treatment for military wives. Psychiatric Services, 65(9), 1170–1173. https://doi.org/10.1176/appi.ps.201300325
Liu, S., Haucke, M. N., Heinzel, S., & Heinz, A. (2021). Long-term impact of economic downturn and loneliness on psychological distress: Triple crises of COVID-19 pandemic. Journal of Clinical Medicine, 10(19), 4596. https://doi.org/10.3390/jcm10194596
Lyons, H. Z., Bike, D. H., Ojeda, L., Johnson, A., Rosales, R., & Flores, L. Y. (2013). Qualitative research as social justice practice with culturally diverse populations. Journal for Social Action in Counseling and Psychology, 5(2), 10–25. https://doi.org/10.33043/JSACP.5.2.10-25
McAuliffe, C., Daly, Z., Black, J., Pumarino, J., Gadermann, A., Slemon, A., Thomson, K. C., Richardson, C., & Jenkins, E. K. (2021). Examining the associations between food worry and mental health during the early months of the COVID-19 pandemic in Canada. Canadian Journal of Public Health, 112(5), 843–852. https://doi.org/10.17269/s41997-021-00557-w
McBain, T. D. (2018). Problems facing the working poor: Implications for counseling. The Hilltop Review, 10(2), 4. https://scholarworks.wmich.edu/hilltopreview/vol10/iss2/4
Mitchell, A. M., Seely, H. D., & Pössel, P. (2022). Intersections of health, economic, and social concerns during the COVID-19 pandemic in the United States. International Perspectives in Psychology, 11(3), 178–187. https://doi.org/10.1027/2157-3891/a000044
Moroz, N., Moroz, I., & D’Angelo, M. S. (2020). Mental health services in Canada: Barriers and cost-effective solutions to increase access. Healthcare Management Forum, 33(6), 282–287. https://doi.org/10.1177/0840470420933911
Nabila Ashraf, M., Jennings, H., Chakma, N., Farzana, N., Islam, M. S., Maruf, T., Uddin, M. M. J., Uddin Ahmed, H., McDaid, D., & Naheed, A. (2021). Mental health issues in the Covid-19 pandemic and responses in Bangladesh: View point of media reporting. Frontiers in Public Health, 9, Article 704726. https://doi.org/10.3389/fpubh.2021.704726
Ollerton, I. (1995). Class barriers to psychotherapy and counseling. Journal of Psychiatric and Mental Health Nursing, 2(2), 91–95. https://doi.org/10.1111/j.1365-2850.1995.tb00148.x
Oser, C. B., Biebel, E. P., Pullen, E. L., & Harp, K. L. H. (2011). The influence of rural and urban substance abuse treatment counselor characteristics on client outcomes. Journal of Social Service Research, 37(4), 390–402. https://doi.org/10.1080/01488376.2011.582020
Oyeka, O., & Wehby, G. L. (2023). Effects of the Affordable Care Act Medicaid expansions on mental health during the COVID-19 pandemic in 2020–2021. Inquiry, 60, Article 469580231166738. https://doi.org/10.1177/00469580231166738
Payandeh, B. (2023). Sociopolitical barriers and considerations for providing psychological services to low-income individuals (Doctoral dissertation. Alliant International University.
Placzek, H., Cruz, S., Chapdelaine, M., Carl, M., Levin, S., & Hsu, C. (2021). Intersecting systemic and personal barriers to accessing social services: Qualitative interviews in northern California. BMC Public Health, 21(1), 1933. https://doi.org/10.1186/s12889-021-11981-5
Rami, F., Searight, H. R., Dryjanska, L., & Battista, P. (2022). COVID-19 International psychology’s role in addressing healthcare disparities and ethics in marginalized communities. International Perspectives in Psychology, 11(2), 80–88. https://doi.org/10.1027/2157-3891/a000035
Ratts, M. J., Singh, A. A., Nassar‐McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. https://doi.org/10.1002/jmcd.12035
Rosas, S. R. (2017). Group concept mapping methodology: Toward an epistemology of group conceptualization, complexity, and emergence. Quality and Quantity, 51(3), 1403–1416. https://doi.org/10.1007/s11135-016-0340-3
Rosas, S. R., & Kane, M. (2012). Quality and rigor of the concept mapping methodology: A pooled study analysis. Evaluation and Program Planning, 35(2), 236–245. https://doi.org/10.1016/j.evalprogplan.2011.10.003
Schnitzer, P. K. (1996). ‘They don’t come in!’ Stories told, lessons taught about poor families in therapy. The American Journal of Orthopsychiatry, 66(4), 572–582. https://doi.org/10.1037/h0080206
Sharir, D. (2017). The link between therapists’ social class attributions and treating clients of low socioeconomic status (Doctoral dissertation, Walden University).
Silas, M. J., & Seward, D. X. (2023). Black women’s help‐seeking and self‐care strategies: A phenomenological exploration. Journal of Counseling and Development, 101(2), 157–166. https://doi.org/10.1002/jcad.12465
Sinclair, V., LaGuardia, A., Saunders, R., & Tichavakunda, A. (2024). Counselors as social justice advocates: Experiences addressing systemic marginalization. Journal for Social Action in Counseling and Psychology, 16(1), 19–42. https://doi.org/10.33043/y6594b8924
Smith, L., Li, V., Dykema, S., Hamlet, D., & Shellman, A. (2013). ‘Honoring somebody that society doesn’t honor’: Therapists working in the context of poverty. Journal of Clinical Psychology, 69(2), 138–151. https://doi.org/10.1002/jclp.21953
Soule, E. K., Jones, D. M., Lovelady, N., Thomas, L., Du, R., Prewitt, T. E., Taylor, E., Baker, S., Guy, M. C., Cornell, C. E., & Fagan, P. (2024). Using Concept Mapping to identify community partners and researchers’ perceptions of Social Justice: A path toward eliminating chronic disease disparities. Health Equity, 8(1), 426–436. https://doi.org/10.1089/heq.2023.0230
Tajan, N., Devès, M., & Potier, R. (2023). Tele-psychotherapy during the COVID-19 pandemic: A mini-review. Frontiers in Psychiatry, 14, Article 1060961. https://doi.org/10.3389/fpsyt.2023.1060961
Thompson, M., Diestelmann, J., Cole, O., Keller, A., & Minami, T. (2014). Influence of social class perceptions on attributions among mental health practitioners. Psychotherapy Research, 24(6), 640–650. https://doi.org/10.1080/10503307.2013.873556
Thompson, M. N., Cole, O. D., & Nitzarim, R. S. (2012). Recognizing social class in the psychotherapy relationship: A grounded theory exploration of low-income clients. Journal of Counseling Psychology, 59(2), 208–221. https://psycnet.apa.org/doi/10.1037/a0027534. https://doi.org/10.1037/a0027534
Thompson, M. N., Nitzarim, R. S., Cole, O. D., Frost, N. D., Ramirez Stege, A., & Vue, P. T. (2015). Clinical experiences with clients who are low-income: Mental Health Practitioners’ Perspectives. Qualitative Health Research, 25(12), 1675–1688. https://doi.org/10.1177/1049732314566327
Thorndike, A. N., Fung, V., McCurley, J. L., Clark, C. R., Howard, S., & Levy, D. E. (2022). COVID-19 stressors and one-year changes in depression and anxiety in a longitudinal cohort of low-income adults in the United States. Preventive Medicine Reports, 26, Article 101730. https://doi.org/10.1016/j.pmedr.2022.101730.
Triplett, N. S., Blanks Jones, J. L., Garfias, Y., Williams, N. D., & Dorsey, S. (2024). Policy for equity: Associations between community mental health agency policies and clinicians’ cultural competence. Health Promotion Practice, 25(6), 951–955. https://doi.org/10.1177/15248399231208422
Trochim, W. M., & McLinden, D. (2017). Introduction to a special issue on concept mapping. Evaluation and Program Planning, 60, 166–175. https://doi.org/10.1016/j.evalprogplan.2016.10.006
Trochim, W. M. K. (1989). An introduction to concept mapping for planning and evaluation. Evaluation and Program Planning, 12(1), 1–16. https://doi.org/10.1016/0149-7189(89)90016-5
Tucker, S. K., Schmit, M. K., & Giordano, A. L. (2021). Perceptions of poverty: Exploring counseling students’ reactions to presenting concerns. Journal of Counselor Preparation and Supervision, 4(14), 1-23.
Watkins, M. (2012). Revolutionary leadership: From Paulo Freire to the Occupy movement. Journal for Social Action in Counseling and Psychology, 4(2), 1–22. https://doi.org/10.33043/JSACP.4.2.1-22
Westergaard, J. (2013). Counselling young people: Counsellors’ perspectives on“what works” – An exploratory study. Counselling and Psychotherapy Research, 13(2), 98–105. https://doi.org/10.1080/14733145.2012.730541
Wolgast, M., Despotovski, D., Olsson, J. L., & Wolgast, S. (2022). Socioeconomic status and the therapeutic alliance: An empirical investigation using structural equation modeling. Journal of Clinical Psychology, 78(6), 1058–1073. https://doi.org/10.1002/jclp.23290
Wolfson, J. A., Garcia, T., & Leung, C. W. (2021). Food Insecurity Is Associated with Depression, Anxiety, and Stress: Evidence from the Early Days of the COVID-19 Pandemic in the United States. Health equity, 5(1), 64–71. https://doi.org/10.1089/heq.2020.0059
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Riley Keast, Marguerite Lengyell, Charlotte Finnigan, Jason Brown, Melissa Jay
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
By submitting to JSACP, the author(s) agree to the terms of the Author Agreement. Beginning in 2018, all authors retain copyrights associated with their article contributions and agree to make such contributions available under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International license upon publication in JSACP. Copyrights to articles published prior to 2018 have been transferred from the authors to JSACP.
