Bennett‐Levy J.

Dohrenwend B. P.

Woodhead C.

English

Delgadillo, J.

White Rose Research Online

This is a repository copy of Worlds apart: Social inequalities and psychological care.White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/128162/Version: Accepted VersionArticle:Delgadillo, J. orcid.org/0000-0001-5349-230X (2018) Worlds apart: Social inequalities and psychological care. Counselling and Psychotherapy Research, 18 (2). pp. 111-113. ISSN 1473-3145 https://doi.org/10.1002/capr.12168© 2018 British Association for Counselling and Psychotherapy. This is an author produced version of a paper subsequently published in Counselling and Psychotherapy Research. Uploaded in accordance with the publisher's self-archiving policy.eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse Items deposited in White Rose Research Online are protected by copyright, with all rights reserved unless indicated otherwise. They may be downloaded and/or printed for private study, or other acts as permitted by national copyright laws. The publisher or other rights holders may allow further reproduction and re-use of the full text version. This is indicated by the licence information on the White Rose Research Online record for the item. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request.   Worlds apart: Social inequalities and psychological care  Jaime Delgadillo1  1. Clinical Psychology Unit, Department of Psychology, University of Sheffield, United Kingdom           Word count (excl. tables and references): 1,410 Correspondence: Dr Jaime Delgadillo, Clinical Psychology Unit, University of Sheffield, Sheffield, UK. Email: jaime.delgadillo@nhs.net Declaration of Interest: None.   Key words: psychological therapy; social inequalities, socioeconomic deprivation Social, educational and economic disparities between therapists and clients are often evident. If psychological therapy exerts its restorative influence through communication and guided action, how can effective communication take place when therapists and clients are worlds apart? As early as the 1950s, it has been recognised that social inequalities pose serious challenges to the practice of psychotherapy (Imber, Nash, & Stone, 1955). Some early studies, for example, noted that low-income patients were less likely to seek mental healthcare (Riessman & Scribner, 1965), and tended to drop out of talking therapies (Overall & Aronson, 1963). The prevailing attitudes and ideas about this matter were poignantly captured in the title of James Heitler’s paper: “Preparatory techniques in initiating expressive psychotherapy with lower-class, unsophisticated patients” (Heitler, 1976). For too long, psychotherapy was seen as a middle-class endeavour for the privileged and educated, where the onus was on the clients to be “psychologically minded” in order to benefit from treatment. In recent decades, however, great strides have been taken to make talking treatments less complicated to explain and to deliver (Bennett-Levy, Richards, & Farrand, 2010). Psychological care is also becoming more culturally sensitive (Bernal & Domenech Rodríguez, 2012), and more accessible to the general population (Clark, 2018). But have we come to understand or address the adverse impact of social inequalities? Today, people living in poverty are still more likely to experience mental health problems (Lund et al., 2010), and are less likely to access therapy (Saxon et al., 2007), and when they do so they are less likely to recover from depression and anxiety problems (Delgadillo, Asaria, Ali, & Gilbody, 2016). Social inequalities continue to be under-researched in our field; rarely acknowledged in clinical training programmes or in the therapy consulting room. It is like an obstacle that is hidden in plain sight; our senses perceive socioeconomic differences effortlessly, but these perceptions may not register consciously in our therapeutic reflections, formulations and actions. This special issue of Counselling and Psychotherapy Research aims to bring the dimension of social inequalities into the foreground of psychotherapy research and practice, gathering a diverse and international collection of original investigations on this topic. The issue begins by presenting a series of large-scale quantitative studies whose findings fit into a coherent pattern, despite being conducted across three countries with distinctive healthcare systems. Socioeconomically deprived areas tend to have an increased prevalence of common mental disorders and greater demand (numbers of referrals) for publicly funded psychological care, but lower treatment access rates irrespective of local variations in the availability of therapists (Delgadillo, Farnfield, & North, 2018). Compared to favourable periods in the economic cycle, periods of financial recession with high unemployment rates also carry evident consequences for mental healthcare. Even when they are able to access and start counselling, low-income clients tend to have higher distress levels at the start and end of treatment compared to high-income clients (Berzins, Babins-Wagner, & Hyland, 2018). This does not mean that low-income clients cannot benefit from therapy; in fact recent evidence demonstrates that clients tend to show improvements in psychological distress and life satisfaction during therapy regardless of income level (Behn, Errázuriz, Cottin, & Fischer, 2018). However, symptomatic improvements appear to predict subsequent improvements in life satisfaction in high-income clients, whereas for low-income clients symptomatic improvements tend to be slower and preceded by gains in life satisfaction (Behn et al., 2018). These contemporary findings lend support to social causation theory (Dohrenwend, & Dohrenwend, 1996), which posits that socioeconomic and environmental adversity is associated with the onset and maintenance of psychological problems. Unemployment and low income may, for example, limit access to health-enhancing goods and services, and only modest gains in life satisfaction might be realistic under these circumstances. Hence, one pathway towards psychological distress may be explained by material deprivation. It is also plausible that a related pathway to distress may be explained by adverse life events. Blackshaw, Evans and Cooper (2018) conducted a systematic review that examined associations between life events, socio-economic status and psychological treatment outcomes for children and adolescents. Starting with a recap on the well-known associations between socioeconomic status and stressful life events (e.g. preventable accidents, abuse, neglect, academic problems), this review synthesises emerging evidence that the relationship between socioeconomic status and treatment outcomes may be partly mediated by the frequency and severity of stressful life events that occur during the course of therapy. Of particular note is their thoughtful observation that, for the individual, stressful life events may lie within a continuum between “no control” and “complete agency”. This point suggests interesting possibilities for clinical practice; could different emotion regulation strategies be useful to cope with different stressful life events? And if so, do social inequalities limit our ability as therapists to support patients in adjusting to and coping with adversity? Dovetailing with clinical practice, a series of survey-based and qualitative studies have explored the relevance of social inequalities from the perspectives of trainees, therapists and clients. Using a vignette-based methodology, Kaiser and Prieto (2018) found that trainee counsellors did not have an apparent bias against working-class clients, but trainees who self-identified as being working-class showed a bias towards upper-class individuals and anticipated having greater difficulties in forming a working alliance with such clients. Trott and Reeves (2018) also examined the relevance of social-class disparities from the viewpoint of qualified therapists who had themselves accessed therapy. Their findings suggest that a lack of awareness and acknowledgement of social-class disparity can damage the therapeutic alliance through inadvertent use of oppressive or classist behaviour; and recognising such disparity can minimise power imbalance and improve rapport. Krause, Espinosa-Duque, Tomicic, Córdoba and Vásquez (2018) also draw attention to the detrimental effect that perceived asymmetry and power imbalance can have on the therapeutic alliance. Furthermore, they pinpoint a series of factors reported by economically disadvantaged clients which act as barriers to effective treatment; geographical and financial impediments to access health centres, culturally-bound prejudices and stigma surrounding mental health problems, and a perceived “clash” of perspectives that may leave clients feeling misunderstood. The theme of cultural diversity is also approached by Moleiro (2018) through a detailed examination of psychotherapists’ cultural awareness and competency, where they were interviewed after being presented with two video vignettes of clients from minority social groups (according to migration status, ethnicity and religious affiliation) and two control vignettes of college students presenting the same complaints. With reference to a range of established multicultural competency frameworks, Moleiro concluded that the majority (70.5%) of rated answers from participants reflected low levels of cultural competency across the domains of openness to differences/attitude, awareness, knowledge, and skills. Joining the dots across studies, we can see that the central notion of social disparity / asymmetry emerges as a likely obstacle to establishing a supportive therapeutic alliance, which may be a necessary condition to effectively support clients to cope with adverse financial and social circumstances.  Many obstacles to treatment utilisation and effectiveness were raised across these studies, attesting to the tremendous challenges that social inequalities pose for the advancement of mental healthcare. An obvious step forward is to better integrate the topics of social inequalities, power imbalance and cultural competency into clinical training programmes. However, our discipline has tended to be rather introspective and focused on the internal world of clients and the relational and technical aspects of the therapy process. Though these aspects are important, an overly insular focus may conceal the broader social, cultural and economic context within which human suffering occurs. Under some circumstances, a positive transformation of a person’s internal world may require a transformation of their external world too; the psychological and social cannot be seen as worlds apart. There are some notable examples that demonstrate this in positive and negative ways. For instance, adjunctive welfare advice yielding financial gains for people with psychological problems improves short-term mental health and well-being (Woodhead, Khondoker, Lomas, & Raine, in press). Neighbourhood deterioration is associated with stress and depressive symptoms, and this relationship has been found to be mediated by changes in social contact, social capital, and perceptions of crime (Kruger, Reischl, & Gee, 2007). Living in urban environments with poor housing quality, noise and pollution is also known to be associated with increased rates of depressive mood after adjustment for individual characteristics (Rautio, Filatova, Lehtiniemi, & Miettunen, 2018). Perhaps our ability to improve the equitability and effectiveness of care for disadvantaged communities may improve when we are better able to integrate insights and evidence from clinical psychology, community psychology and social psychology.              References Behn, A.J., Errázuriz, P.A., Cottin, M., & Fischer, C. (2018). Change in symptomatic burden and life satisfaction during short-term psychotherapy: Focusing on the role of family income. Counselling and Psychotherapy Research, X(X), XX-XX.  Bernal, G., & Domenech Rodríguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association.  Berzins, S., Babins-Wagner, R., Hyland, K. (2018). Relationship of employment status and socio-economic factors on distress levels and counselling outcomes during a recession. Counselling and Psychotherapy Research, X(X), XX-XX.  Blackshaw, E., Evans, C., & Cooper, M. (2018). When life gets in the way: Systematic review of life events, socioeconomic deprivation, and their impact on counselling and psychotherapy with children and adolescents. Counselling and Psychotherapy Research, X(X), XX-XX.  Bennett-Levy, J., Richards, D., & Farrand, P. (2010). Low intensity CBT interventions: A revolution in mental health care. New York, NY: Oxford University Press.  Clark D. M. (2018). Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology, 14,1. doi: 10.1146/annurev-clinpsy-050817-084833  Delgadillo, J., Asaria, M., Ali, S., & Gilbody, S. (2016). On poverty, politics and psychology: The socioeconomic gradient of mental healthcare utilisation and outcomes. British Journal of Psychiatry, 209(5), 429-430. doi: 10.1192/bjp.bp.115.171017  Delgadillo, J., Farnfield, A., North, A. (2018). Social inequalities in the demand, supply and utilisation of psychological treatment. Counselling and Psychotherapy Research, X(X), XX-XX.  Dohrenwend, B.P., & Dohrenwend, B.S. (1996). Social status and psychological disorder; a causal inquiry. New York, NY: Wiley-Interscience.  Heitler, J. B. (1976). Preparatory techniques in initiating expressive psychotherapy with lower-class, unsophisticated patients. Psychological Bulletin, 83, 339-352. doi: 10.1037/0033-2909.83.2.339  Imber, S., Nash, E., & Stone, A. (1955). Social class and duration of psychotherapy. Journal of Clinical Psychology, 11, 281. doi: 10.1002/1097-4679(195507)11:3<281:AID-JCLP2270110308>3.0.CO;2-U  Kaiser, D.J., Prieto, L.R. (2018). Trainee estimates of working alliance with upper and working class clients. Counselling and Psychotherapy Research, X(X), XX-XX.  Krause, M., Espinosa, H., Tomicic, A., Córdoba, A., Vásquez, D. (2018). Social inequality and depression: A threefold burden. Counselling and Psychotherapy Research, X(X), XX-XX.  Kruger, D. J., Reischl, T. M., & Gee, G. C. (2007). Neighborhood social conditions mediate the association between physical deterioration and mental health. American Journal of Community Psychology, 40(3-4), 261-271.  Lund, C., Breen, A., Flisher, A. J., Kakuma, R., Corrigall, J., Joska, J. A., . . . Patel, V. (2010). Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science & Medicine, 71(3), 517–528. https://doi.org/10.1016/j.socscimed. 2010.04.027  Moleiro, C. (2018). Integrating diversity into therapy processes: The role of individual and cultural diversity competences in promoting equality of care. Counselling and Psychotherapy Research, X(X), XX-XX.  Overall, B., & Aronson, H. (1963). Expectations of psychotherapy in patients of lower socioeconomic class. American Journal of Orthopsychiatry, 33, 421. doi: 10.1111/j.1939-0025.1963.tb00376.x  Rautio, N., Filatova, S., Lehtiniemi, H., & Miettunen, J. (2018). Living environment and its relationship to depressive mood: A systematic review. International Journal of Social Psychiatry, 64(1), 92-103. doi: 10.1177/0020764017744582  Riessman, F., & Scribner, S. (1965). The underutilization of mental health services by workers and low income groups: Causes and cures. American Journal of Psychiatry, 121, 798-801. doi: 10.1176/ajp.121.8.798  Saxon, D., Fitzgerald, G., Houghton, S., Lemme, F., Saul, C., Warden, S., & Ricketts, T. (2007). Psychotherapy provision, socioeconomic deprivation, and the inverse care law. Psychotherapy Research, 17(5), 515-521. doi: 10.1080/10503300601063246  Trott, A., Reeves, A. (2018). Social class and the therapeutic relationship: The client’s perspective. To what extent do perceived differences in social class between client and therapist impact upon the therapeutic relationship? A qualitative study using a questionnaire survey. Counselling and Psychotherapy Research, X(X), XX-XX.  Woodhead, C., Khondoker, M., Lomas, R., & Raine, R. (in press). Impact of co-located welfare advice in healthcare settings: Prospective quasi-experimental controlled study. British Journal of Psychiatry. doi: 10.1192/bjp.bp.117.202713  

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