Research Review: social class and counselling

Report Compiled by Dr Morag MacSween, for Aurora New Dawn and Independent Domestic Abuse Services

I’d never have counselling. I don’t have the time. And I don’t want to sit there with some woman looking down her nose at me.

Domestic Violence Lived Experience Advocate

After a conversation including this comment, I was asked to review what the literature tells us about class and counselling for an Australian domestic violence agency. This paper summarises open-access material found by searches using counselling, class, social class and client perspective, relying primarily on meta-analyses. The bulk of the literature was from the UK proved to be true.

I wanted to find out what counsellors and service managers made of the findings, and talked to a small group of people in Australia and the UK.

The most significant feedback by far was that social class is a forgotten issue, and that my paper raised important issues which should be more broadly considered.

One service manager, while giving that feedback, also commented on a degree of wariness that this learning could be misused in the context of the continuing need to advocate for increased funding for counselling. One counsellor, again agreeing with the main slant of feedback, commented that counselling in her view is often denigrated and talked about and represented in patronising ways. For her, this links to the fact that counselling is a female-dominated area of work, which deals with emotions. And one service manager commented that it is my middle-class privilege which allowed me the time, space and access to write this piece. This is undoubtedly true, and I acknowledge that I write from a position of privilege.

The practical outcome of these discussions was adapting this paper for Aurora New Dawn and IDAS to share with sister agencies in England.

I would be delighted to get further feedback from anyone who reads this piece.

Key Themes

The neglect of class

All of the research located noted that class is a neglected aspect of the consideration of diversity in counselling research. In the literature review for her Masters of Counselling thesis, Social Class and the Therapeutic Relationship: the client’s perspective, Alison Trott found that:

there is much less research on the intersection of class and therapy than on the intersections of race, culture, sex, gender, age and sexual orientation; and
most of the available research is from the therapist’s perspective. ^[i]

Sarah McDermott also argues that social class is a neglected aspect in counselling research, and is also neglected in practice and in training. ^[ii]

The significance of class – in life, in mental health, and in counselling

The research argues that class, while neglected, is significant – both in its own right, and in counselling. Ballinger and Wright argue that social class is a key component of personal identity, that it shapes life-style and life chances, impacts on how we relate interpersonally, and on our language, values and worldview. ^[iii] They argue that class identity is to an extent subjective, and that our own assessment of our class may differ from that of others. Our class identity intersects with other aspects of our identity such as race, sex and sexuality. Class is a strongly emotional issue, linked to our parents’ emotional reaction to their class.

They also argue for the existence of a mental health class gradient:

the poorer you are, the more likely you are to be diagnosed with mental health problems; and
the greater the social gap between the labeller and the labelled, the more serious the label that is likely to be given.

Class is also significant in counselling. US research has consistently demonstrated social class differences in access to, and outcomes of, psychotherapy. In their study, Influence of Social Class Perceptions on Attributions among Mental Health Practitioners, Thompson et al summarise the existing research.^[iv] Working class clients show less improvement in depression scores, and are:

less likely to access therapy;
more likely to be referred to supportive rather than insight-oriented therapy; and
more likely to discontinue therapy.

Trott also argues that there is some evidence that the most disadvantaged clients are more likely either to terminate therapy prematurely or to develop dependency.^[v]

McDermott argues that class oppression results in material disadvantage and reduced life choices, and that ignoring this impacts significantly on therapeutic relationships and outcomes. Discussing humanistic counselling she argues:

while the core conditions of congruence, empathy and unconditional positive regard are intended to equalise power in therapy, their acceptance into the mainstream has meant that the focus on the revolutionary removal of marginalisation and oppression in counselling has decreased.^[vi]

Trott argues similarly, quoting Procter:

Person-centred theory theorizes distress as incongruence or internalized conditions of worth, clearly placing the problem as internal. Thus, therapy tries to change the individual whilst leaving society and the inequalities in society unchanged.^[vii]

Ballinger and Wright argue for a possible correlation between class background and theoretical approach; a class-like hierarchy in terms of the status accorded to different theoretical approaches:

In the class system, the skilled labourer is above the labourer but well below the architect. Is being person-centred the equivalent of being a brickie, the architect the psychoanalytic practitioner?

They also argue that this can be subverted, with listening to the unlistened to… a political act. ^[viii]

Woman counselling a classy client

Class and the counsellor

There is a strong focus on the potential risks and omissions where the counsellor is middle-class and the client working-class. Ballinger and Wright note the risks as:

the counsellor failing to see the social context of problems;
the counsellor failing to see the impact of the social context on the individual’s ability to choose and maintain a sense of their own agency;
potential disempowerment of the client;
communication negatively impacted by different language system and codes; and
different life experiences impacting negatively on the development of empathy. ^[ix]

Trott’s review of the literature found that:

class consciousness varies by class, with class blindness more common in middle- and upper-class people;
where therapists ignore, are not conscious of, or poorly understand the impact of class and/or working-class values and/or a working-class frame of reference, therapeutic progress stalls;
therapists who are unaware of their own social class may assume their experience to be (shared) reality, impose their values on the client, and/or reproduce stigma and classism experienced in the client’s life outside therapy; and
therapists who adhere to the Just World Belief are most likely to view working-class clients negatively. ^[x]

Thomposen et al note that studies have found that therapists working with working class clients are more likely to:

attribute higher levels of personal responsibility… for causing and solving (their) problems;
rate symptoms as more serious; and
rate engagement and success in therapy as lower.

They note one study which argues that stories regarding clients from low-income backgrounds have been passed along within psychotherapy circles that reveal unexamined classist assumptions about individuals who are poor, including: “they don’t come in”, “they’re so disorganized”, and “they don’t care”. However, they also note other studies which report under-diagnosis of issues in middle- and upper-class clients, and no difference in attribution of internal or external causes of distress between class groups.

Thomposen et al’s own study found that practitioners noticed social class but did not have more negative views and attributions in relation to working-class clients. They argue that this could mean that there is increased awareness of the impact of structural disadvantage on individual difficulties, aligning with research which found that increased exposure to poverty via the media is related to individuals’ heightened awareness of its systemic and harmful effects. They note however that their results could suggest that therapists in the study provided the politically correct response.^[xi]

The literature also includes exploration of the experience of being a working-class counsellor and its capacity to increase empathy:

Going to university was above my station. I remember feeling fear, inferior, not belonging. I was waiting to be found out.^[xii]

Trott argues that talking therapies are based on dominant white, Western, middle-class values, and that class is an elusive, but powerful force within the therapeutic relationship. She shares her own experience, as a client…

As a vulnerable client, my first experience of personal therapy proved extremely distressing, reinforcing my own feelings of powerlessness and inferiority. I assumed my therapist was upper-middle-class due to her home, car and oration. How could this person truly understand what it was like for me, with working-class roots, living as a single parent on benefits? I could not connect with her and, needless to say, I did not return

…and as a counsellor:

Now, as a therapist working in the National Health Service in a deprived part of Wales, I regularly see clients with chaotic backgrounds and complex needs, often as a result of poverty…I believe my own working-class background, together with being class conscious, enables me to connect with clients more fully than might be the case were I ‘class-blind’ and from a more affluent milieu.^[xiii]

Class difference

The literature also includes studies which suggest that it is the difference in social class background between client and therapist which accounts for these issues, rather than the attitude of the therapist.

In a meta-analysis of dropout rates, one study suggests that higher dropout rates among working class clients may relate to client-therapist differences in education, value systems, and expectations concerning the nature and duration of therapy. Another study suggests that therapists are more able to empathise with clients from a similar social class background. Research into client perspectives suggest that working class clients may withhold information because they think their therapist may not understand, empathise or meet their needs because of their middle-class background.^[xiv]

Trott argues that class disparity is a particular feature of public and not-for-profit counselling which are more accessible to, and more widely used by, working class clients, and that class consciousness, as well as class itself, is likely to impact the therapeutic relationship. She notes that there is some evidence that class similarity is helpful in reducing tension and promoting alliance; but that a strong therapeutic alliance, particularly empathy, remains most helpful in terms of outcomes. She argues that there is a risk that the therapist could assume too much and/or collude with their client where they were from the same class. Where clients thought that they came from a different class background as their therapist, empathy and explicit recognition of class difference were found to improve outcomes.^[xv]

In A Client Informed View of Domestic Violence Counselling, Jeanette Roddy found that:

despite many respondents believing social class to be an irrelevant factor within their therapeutic relationship… social class was a silent but powerful force affecting clients’ feelings of equality, which were often ignored.^[xvi]

Where clients thought that they came from the same class background as their therapist, they felt intuitively understood and experienced a more effective therapeutic alliance.

The working-class client

Ballinger and Wright argue that in working class culture, there can be antagonism towards counselling, counselling can be seen as a sign of weakness and therapists as elitist. In addition, there are financial barriers to access.^[xvii]

Trott’s review of the literature found that working-class clients’ experience with middle-class therapists includes:

anger/jealousy over therapists’ privilege, particularly when class status symbols were highly visible e.g., when therapy took place in the therapist’s home;
feeling uncomfortable, disempowered, judged, blamed, humiliated and/or inadequate;
feeling patronised and insulted when the therapist used their own frame of reference as ‘reality’ or ignored class;
feeling inferior and not understood, and either withholding information or withdrawing from therapy, or adopting confrontational attitudes possibly in an attempt to redress the balance of power in their favour;
working-class clients value class being named in therapy, and see this as the therapists’ responsibility; this is an area where skilful self-disclosure is helpful;
finding humanistic approaches warmer and more human than psychotherapeutic approaches; and
finding it helpful for therapists to amend their language and speech so that it is more understandable.^[xviii]

McDermott argues that clients from working-class backgrounds form their identify and sense of self in oppressive conditions of worth and may be significantly less familiar with a non-judgemental relationship.^[xix]

Client perspectives on what works

Roddy’s study includes a review of the then (2014) available research on clients’ perspectives of DV counselling.^[xx] She found:

a lack of literature on the client view of DV counselling and more strikingly…a lack of research investigating why counselling (rather than support) might work and the value of counselling to clients.

With caveats, she concludes that the outcomes clients experienced were three-fold:

improved problem solving, autonomy, coping strategies and confidence to get on with life;
increased understanding of their experiences; and
seeing a future again.

What was important in counselling was:

having the abuse acknowledged;
being supported to find their own solutions to their own self-defined problems; and
having access to an appropriate therapist.

Roddy points out that these outcomes and features are not specific to counselling, but are relevant across all DFV services. She hypothesises that the specific value add of counselling could be addressing trauma through a more significant process than one of simply psycho-education.

Class-informed counselling

All the research located emphasises the critical importance of working actively and explicitly with class in counselling. For example, Trott argues:

For a client to take full benefit from therapy therapists must recognise the importance of social class and classism and the impact these have upon the therapeutic relationship, and be prepared to attend to these dynamics when appropriate.^[xxi]

In their think piece, Cultivating social class awareness in the counseling profession, Derrick Shepard and Eva Gibson reflect on their own social class backgrounds and how they may impact their work as counsellors.^[xxii] They note that they were used to reflecting together on their race similarities and sex differences, but that they talked less about class.

Shephard notes that he is by background aware of the systemic barriers to therapy for working-class clients. Gibson notes heightened awareness of ‘representational responsibility’ when she was a client herself in therapy:

…it felt different sitting in the client seat. I felt this urge to “put on my best face” because I did not want to present as a client with problems but rather as a responsible, proactive citizen. I felt as if the counselor needed to see the best of me, and because I fell in the middle-class, college-graduate category, I needed to behave accordingly.

To be completely honest, I am not sure to what degree these feelings were due to my identity as a middle-class client and to what degree they were due to my identity as an African American woman. As a professional black woman, I constantly feel as though I have to wear a mask. I fear letting my vulnerabilities and struggles show because I represent not only myself but also my people.

I was concerned about how the counselor would view me…(this)…acted as a barrier and prevented any real work from being done.

They argue for the inclusion of social class in the therapeutic alliance through:

counsellor reflection on their own social class background, how it has changed, and how they relate to people of the same class, a higher class, and a lower class, and whether they experience internalised classism;
what their own experience means for their capacity to notice the social class microaggressions that take place every day;
having open conversations with clients from the outset about how they perceive their social class, and how this impacts on their expectations of themselves, others’ expectations of them, their values and their goals; and
continuing professional development, in particular researching and submitting on social class and counselling.

Understanding class, understanding domestic violence

There are significant overlaps between the research on class-informed counselling and Roddy and Gabriel’s work on developing a competency model for domestic violence counselling.^[xxiii] They argue for specific competencies in DV counselling because core features of the experience of violence impact on the effectiveness of the core conditions of generalist counselling:

Someone who stays safe by focusing on the needs of their partner and diverting attention away from themselves, may find an environment focused on themselves unsafe or frightening. An individual who has not been allowed to make any decisions may find a collaborative, objective setting process for therapy challenging and may simply agree with therapist ideas. It can… be difficult to build the therapeutic alliance with someone who has learned over a long period of time not to trust, disclose or become close to anyone.

They argue that counsellors experienced in working with DV clients may implicitly understand the need to work differently.

Closed access resources

The following closed access resources may be worth purchasing.

Counseling People Living in Poverty: The CARE Model by Foss LA, Generali MM and Kress VE, Journal of Humanistic Counselling 2011

Abstract

Counselors frequently counsel clients who live in poverty. The authors describe the new CARE model that addresses the influence of multiple systems on poor clients’ experiences. A social justice, humanistic intervention, the CARE model emphasizes cultivating a positive counseling relationship with poor clients, empathizing with their unique realities, and working to remove barriers to future success and well‐being by building on their strengths.

A New Framework to Understand Social Class in Counseling: The Social Class Worldview Model and Modern Classism Theory Liu WM, Soleck G, Hopps J, Dunston K, Pickett T, Journal of Multicultural Counseling and Development 2011

Abstract

Because social class and classism remain elusive constructs in psychology, this 2‐part article first lays the foundation for the Social Class Worldview Model and then the Modern Classism Theory. A case example is used for illustration. The authors also provide counseling applications and recommendations for future research.

McDermott suggest that the Model assists counsellors to understand how clients view themselves, their environments and others in terms of social class…(and)…the schema people use to make sense of their social class perceptions, feelings, economic environments and culture.^[xxiv]

Discussion

No literature comparing attitudes to counselling compared with other forms of support was found. However, Roddy’s study of client perspectives on DV counselling found that the outcomes valued by clients were common across support services, rather than specific to counselling. She hypothesises that counselling includes deeper exploration and resolution of trauma, but notes that her research does not provide direct evidence of this.

Four findings from my review of the effectiveness of DFV counselling by duration are relevant to this discussion:

The literature suggests that established best practice in domestic, family and intimate partner violence counselling is a continuum of services, including individualised short-term counselling and advocacy, longer-term trauma counselling, and outreach.
^[xxv]MacSween M Rapid Evidence Assessment: the effectiveness of Family and Intimate Partner Violence counselling by duration 2021
While there is evidence of the effectiveness of longer-term intensive psychotherapy, including group therapy, the bulk of the evidence is for the effectiveness of bespoke fixed-term programs.
^[xxvi]MacSween M Rapid Evidence Assessment: the effectiveness of Family and Intimate Partner Violence counselling by duration 2021
There is moderate evidence that interventions which focus on building skills have positive effects on victim/survivor coping skills, well-being, decision-making abilities, and safety;
^[xxvii]MacSween M Rapid Evidence Assessment: the effectiveness of Family and Intimate Partner Violence counselling by duration 2021

and
In a review of a range of DFV services – emergency shelter, advocacy, counselling, safety planning and support groups – the outcomes found to be helpful were common across all interventions:

psycho-education about the causes and consequences of IPV;
attention to ongoing safety concerns; and
a focus on survivors’ strengths.^[xxviii]

Taking these findings together, it is likely that a continuum of support services, including but not limited to counselling, is likely to better meet the needs of clients as a whole.

While the evidence base on class-sensitive counselling is small, it is remarkably consistent, giving a clear picture of good practice.

Report Compiled by

Dr Morag MacSween, for Aurora New Dawn and Independent Domestic Abuse Services

Consultant – Coach – Clinical Supervisor

April 2022

Contact details:

moragmacsween@outlook.com

https://www.linkedin.com/in/morag-macsween-04395613b/

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