TPC-Journal-V4-Issue4

The Professional Counselor \Volume 4, Issue 4 391 There is agreement regarding the multicultural and social justice relevance of economic empowerment and SES in the field of counseling (Ratts, Toporek, & Lewis, 2010); however, available SES counseling literature is predominantly conceptual and not empirical. There are several possibilities for the overall lack of empirical investigations into SES and counseling outcomes. First, only recently have mental health counselors made a concerted effort to empirically demonstrate counseling outcomes (Hays, 2010). In addition, Smith, Chambers, and Bratini (2009) opined that, while research on the pathogenic impact of poverty on emotional well-being is robust and logical, the development of practitioner-based interventions has been limited. The counseling profession has not been a leader in empirically studying this complex variable, which further limits the profession’s contributions to research-based interventions. Moreover, SES is complex (Liu et al., 2004); its etiology is often interconnected with mental health risk factors. One challenge of SES research, then, is effectively conceptualizing which aspect of the variable to address first. This challenge is best expressed in the old adage “Which came first, the chicken or the egg?” In other words, do lower SES levels lead to higher rates of mental health disorders or do higher rates of mental health disorders lead to lower SES levels? Eaton, Muntaner, Bovasso, and Smith (2001) identified four possible answers: (a) Lower SES raises the risk of developing a mental health disorder, (b) lower SES prolongs the duration of a mental health disorder episode, (c) mental health disorders lead to downward social mobility or (d) mental health disorders hinder attainment of upward SES status. It also is plausible that these answers are not mutually exclusive, further complicating the role of SES in mental health. Objective Versus Subjective Indicators of SES Another possible reason for the limited pursuit of SES research is the difficulty in operationalizing SES. As a construct, SES is multifaceted, impeding the use of discrete variables (Liu et al., 2004). Frequently it is measured using objective, actuarial data such as household income, occupation, zip code and healthcare coverage. However, Braveman et al. (2005) demonstrated that objective indicators of SES, such as education and income, are inadequate because they are not interchangeable with other SES indicators of wealth, education and neighborhood (e.g., zip code clusters). Braveman et al. (2005) concluded that better measures were needed, especially subjective SES measures, such as perceptions of financial security and broad, culturally driven definitions such as lower-, middle- and upper-class SES levels (Adler et al., 2000; Dennis et al., 2012). Other researchers have reached similar conclusions after using both subjective and objective markers of SES (Adler et al., 2000; Hillerbrand, 1988). Even formal measures of SES, including the Hollingshead’s SES indicator (Hollingshead, 2011) and the Duncan Socioeconomic Index (Duncan, 1961), make limited use of subjective measurement strategies. Liu, a leading advocate for the study of SES in counseling, emphasized the need for a multidimensional approach for data collection to best capture contemporary client experiences (Liu, 2011; Liu et al., 2004). In this article, we integrate subjective and objective variables and examine their impact on clinical outcomes. SES and Clinical Outcomes In general, psychotherapy reviews show that higher SES is associated with greater therapy retention (Clarkin & Levy, 2004; Petry, Tennen, & Affleck, 2000). However, SES is not consistently related to symptom reduction (Petry et al., 2000). On the other hand, SES does relate to counselor perceptions of the client. For example, in one study at a university counseling center, 163 case files were randomly selected to evaluate the association between the Hollingshead SES rating scale and therapy outcome (Hillerbrand, 1988). According to the results, counselors rated clients with lower SES levels as having greater dysfunction, greater goal disagreement about treatment and less successful counseling outcomes. Mental health practitioners have perceived clients as less motivated when they have lower SES levels (Leeder, 1996) and lack similar social support (Beatty, Kamarck, Matthews, & Shiffman, 2011). In another study, counselors and counselor trainees rated case vignettes and videos of presenting problems featuring clients from either lower or higher SES (Dougall & Schwartz, 2011).