Attending to client background, lived experiences, and interactions with mental health systems is essential to provide competent and effective care. As psychotherapists, we are well aware of the importance of the common factors and do our best to establish a strong working relationship with our clients to help them thrive. The last thing we want to do is to act upon personal assumptions, biases, or beliefs that could negatively impact our relationship with our clients. Yet, as humans, shedding these personal reactions and ensuring that our beliefs do not alter our clinical practice can be challenging.

In a recent paper (Thompson, Chin, & Kring, 2019), we demonstrated some of the ways that mental health clinicians’ perceptions of clients may shift given information about a client’s social class and sexual orientation. We used a video vignette-based quasi-experimental design to examine the influence of client social class and sexual orientation on 257 licensed mental health clinicians’ perceptions of a hypothetical woman client across six criteria. Results showed that the mental health clinicians’ in this sample noticed the client’s social class and sexual orientation, and that these client characteristics affected perceptions of the client, most notably those based upon social class cues. As hypothesized, participants who viewed the client portrayed as being a member of a low social class group rated her as having heightened symptoms of depression and anxiety, as being less satisfied at work, and as having lower levels of meaningful work and flourishing as compared with the participants who viewed the client portrayed as being a member of a higher social class. Participants did not rate the hypothetical clients differently on symptoms of depression, anxiety, meaningful work, or job satisfaction based upon client sexual orientation, but did rate the lesbian client as having significantly higher levels of flourishing as compared to the straight client.

What is Social Class?

Social class is a complex cultural variable that has been shown to relate to access to treatment, experiences within the therapy room, and treatment outcomes. Yet, it remains an understudied construct within psychotherapy literature and questions remain about the presence of social class biases among mental health clinicians (Appio et al., 2013; Lott, 2002; Smith, 2005).

To think about social class further, I invite you to take a moment to pause and reflect upon this question:

How do you describe your social class?

I often use this when I present on the topic of social class to groups of individuals. Responses vary widely. Some people talk about the past (i.e., how I grew up) whereas others talk about the present (i.e., my amount of student loan debt). Some describe level of education or occupation held by themselves or their parents. Others share their subjective beliefs about the social class category to which they belong. And some describe access to specific resources, or lack thereof, that contribute to their understanding of themselves as compared to others (e.g., ability to afford stable housing, access to neighborhood or community support, participation in leisure activities). Almost no one talks about how much money they earn or possess, which is the traditional way social class is measured.

As you can imagine, when I hear from a handful of individuals’ responses to the question, the complexity of social class begins to become apparent. Social class is a cultural variable, a worldview, and a lived experience (Liu et al., 2004). Our beliefs and values around money and access to resources are intertwined with our experiences (such as the schools we’ve attended, neighborhood in which we live, and work experiences) and identities (including sexual orientation, gender, race and ethnicity, religious and spiritual beliefs). These attitudes and beliefs are influenced by, and embedded within, social structures. For example, those of us living in the United States have no doubt internalized societal messages of meritocracy – or the promise that if we just work harder, we can improve our social class and achieve the so called American Dream, which is assumed to be equally available to all (Lee & Dean, 2004). The flip side of these beliefs also has been internalized: those who have not improved their social class didn’t work hard enough and therefore deserve their social position.

Social Class and Psychotherapy

Social class matters to our clients and it matters to us as psychotherapists. It is present in the therapy room and has implications for our perceptions and interactions. As Liu and colleagues (2004) described in their Social Class Worldview Model, as psychotherapists, we bring our social class worldview into the room. Similar to our results, others have demonstrated that psychotherapists notice social class and that perceptions of client social class can have implications for therapists’ attributions toward clients (e.g., Falconnier & Elkin, 2008; Smith et al., 2011).

Social class also matters to our clients. Lower levels of social class and heightened economic insecurity and poverty have been well documented to relate to health disparities, educational and occupational trajectories, and wellness. In the therapy room, clients notice explicit and implicit social class markers (e.g., pictures of vacation destinations, our clothing), which highlight evident differences in income (Goodman, Pugach, Skolnik, & Smith, 2013; Thompson, Cole, & Nitzarim, 2012).

It’s probably not surprising that even in the therapy room, conversations related to social class can feel uncomfortable. Indeed, most of us don’t know how to talk about money, whether in public spaces or within our families (Tonigan & Hurwitz, 2014; Thompson et al., 2018). In prior research, both clients and psychotherapists have articulated some of the ways that conversations related to social class elicit emotional reactions (Thompson et al., 2012; Thompson et al., 2015) for clients (e.g., isolation, envy, embarrassment) and psychotherapists (e.g., shame, fear, embarrassment). Yet, evidence suggests that when therapists approach (rather than avoid) economic stress topics with clients in session and do so in a way that explicitly acknowledges and integrates an understanding of social class into treatment, positive client experiences and outcomes can result (Falconnier & Elkin, 2008; Thompson et al., 2012).

Increasing our Understanding of Social Class and its Implications of Our Work with Clients

In our paper (Thompson et al., 2019), we drew from scholars and clinicians to summarize some ways that we can gain greater awareness of our own assumptions, beliefs, and biases related to social class to mitigate the potential that they will negatively impact our ability to build strong working relationships with clients. I expand on a few of those suggestions here:

• Remember that social class is a complex cultural variable. It’s important that we make efforts to understand client’s individualized experiences rather than relying upon stereotypes to categorize them into particular groups and form impressions. For example, we should not assume to know what it means if a client shares with us that they are “working class” or says that they are experiencing “economic insecurity.” Instead we want to take time to learn more about their lived experiences and identities that contribute to their understanding of themselves and to their presenting concerns. It is important for us to recognize the ways that we may fall victim to a tendency to stereotype clients into particular social class groups based upon one piece of information, which can subsequently affect our tendency to over- or under-pathologize clients or miss critical information impacting their lives.
• We all can benefit from spending time reflecting upon our own economic cultures and life experiences that have implications for how we perceive and interact with clients whose economic cultures may be similar to, or different from, our own (Liu et al., 2004). For example, it is important for us to examine how we understand social class, in terms of its definition and how it has functioned in our own life to open or close doors, shape our understanding of ourselves, and facilitate belongingness (or lack thereof) within particular spaces. We want to interrogate the extent to which we have bought into beliefs that serve to reinforce class-based stereotypes and systems of oppression (e.g., beliefs that the world is fair and that people get what they deserve [Just World Beliefs], beliefs that if people work hard then they will be successful [Protestant Work Ethic], and assumptions that everyone has equal opportunity to succeed [Myth of Meritocracy]). Finally, we want to seek feedback on and acknowledge the ways in which we contribute to classism in our practice, teaching, research, and everyday interactions.
• While a focus on work is often de-emphasized in traditional theories of psychotherapy, work plays a central role in individual’s lives and has implications for health and wellness (Blustein, 2006). Work also is inherently interconnected with economic insecurity, social prestige, social power, and identity (Thompson & Dahling, in press). In our paper (Thompson, Chin, & Kring, 2019), we examined the presence of mental health clinicians’ assumptions and biases toward clients based upon the client’s work-related information. Results showed that participants who viewed the video vignette of the client who stated that she works in a grocery store rated her as having lowered levels of meaningful work and as being less satisfied in her job as compared with those who viewed the vignette of the client who stated that she works as a lawyer in a small law firm. This finding emerged even though no other information about the client’s career history, intended career trajectory, or affective responses toward her work was provided. In addition, participants indicated that the client portrayed as lesbian had higher levels of flourishing and was perceived to have similar levels of job satisfaction and meaningful work as compared to the client portrayed as straight even though the lesbian client stated explicitly, “My coworkers don’t know about my girlfriend or know that I am a lesbian, so I’m scared to be myself at work. I’m afraid that they’ll judge me and that my boss won’t promote me.” In combination, these findings suggest that it is important for us to carefully consider the intersections of social class with work. As psychotherapists, we want to examine tendencies we may have to miss or downplay client’s experiences with systemic stressors and discrimination as well as to interrogate our own assumptions about what is considered meaningful and satisfying work. Such assumptions may negatively affect our ability to fully appreciate client’s lived experiences, which may have detrimental implications for our ability to develop a strong alliance.
• In increasing our understanding of social class as a complex cultural variable, it is important for us to recognize that social class is not static. Jobs change or go away. People move. Health problems emerge. New family members come along. Relationships dissipate. All of these life events (and more) have implications for one’s level of economic security, financial stress, and access to participate in activities to promote wellness. As such, it is important for us to acknowledge that when working with clients over time, their social class may change, and these changes in mobility (upwards and downwards) can become stressors for clients. For example, a client who class jumps or experiences a downward shift in social class may experience disconnection from family and community, shame or guilt, fear, and isolation from members of their new social class group. Instead of viewing our understanding of a client’s social class as done following our intake session, we want to pay attention to cues from clients that may suggest that these factors have changed, and revisit as needed throughout out work together.
• In order to further address our assumptions and beliefs related to social class, we also want to attend to the presence of implicit bias (Plant & Devine, 1998). We can seek out opportunities to participate in bias reduction interventions to gain awareness of our tendencies to respond in biased ways, gain knowledge to replace our biases, and become motivated to take action to eliminate our biases (Devine, Forscher, Austin, & Cox, 2012; Devine et al., 2017). Deliberately incorporating conversations about client and psychotherapist social class into clinical supervision offers one mechanism by which we can begin to explore our internalized beliefs and understand how they may be affecting our countertransferential reactions or our tendencies to approach versus avoid certain topics with clients in session.

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