Louise and her two children--Joseph, 10, and Anita, 6--live in one of Chicago's poorest housing projects, surrounded by high crime, drug dealers and violence. Her job as a food service worker pays minimum wage--barely enough to feed her kids. Joseph is in trouble at school constantly, fighting with other kids, talking back to teachers, playing hooky. Just 25 years old, Louise already feels overwhelmed by life and hopeless that anything will ever change. She spends her evenings staring at the TV, sinking deeper into depression. Her older sister, Sally, and their mother have tried to help Louise and the kids, without success. Joseph's teachers have urged Louise to set firmer limits, but she just doesn't have the energy. She did go to a conference at the school with Joseph's teachers and school counselors, and after much discussion, they suggested she take the family to the local community mental health clinic for therapy.
Louise called the clinic to make an appointment for the family, as she'd been told to do. But after making the appointment, she begins to have second thoughts: where will she find an extra $5 to pay for the session, when she couldn't pay her bills last week? How will they find transportation to the clinic, and will she and the kids make it back home safely through the neighborhood? And lurking behind all those worries is the nagging fear that she would be blamed for Joseph's behavior. Her mother has told her about people who go to the clinic and lose custody of their children. Still, Louise is determined to be there for the appointment. But when she tells the children about going for counseling, they flatly refuse, and she has no idea how to get them to attend.
After Louise missed the appointment, the intake worker politely called and encouraged her to try again, but with no success. Louise becomes more lethargic and depressed, and Joseph spends more and more time with other kids in trouble.
The prevalence of stories like Louise's is confirmed by clinical research, which has established that traditional psychotherapy has a less-than-impressive track record with people in poor communities. Fortunately, research is finally beginning to offer a picture of what works best for clients whose problems are entangled with dangerous neighborhoods, social isolation and lack of economic opportunities. In recent years, we have also seen researchers move from asking how therapy works with the poor, a question too general to be useful, to the far more instructive study of how therapy can best have an impact on the specific kinds of problems most likely to affect those living in poverty.
In 1995, 11 percent of the families in America (36 million people) lived below the poverty level ($15,500 for a family of four) and more than 20 percent of children lived in poverty. Thirty percent of African Americans, thirty percent of Hispanics and fifty percent of African American children lived in poverty. Research shows that levels of stress, number of individual psychological problems, marital and family difficulties and severe mental illness increase as socioeconomic status declines. For example, having a low income increases the likelihood of depression, schizophrenia, anxiety and psycho-physiological distress in adults and psychological distress in adolescents. In Leo Srole's and his associates' classic 1962 Midtown Manhattan Study, which examined the relationship between socioeconomic status and mental health, lower-income individuals were overrepresented among those who had significant difficulties in coping, a finding consistently replicated over the years.
Despite the greater incidence of psychological stress, research assessing mental health treatment shows that poor clients are less likely to use psychotherapy, compared with those with more financial resources. …