Increasing the Effectiveness of CBT with Low SES Clients

The income inequalities in the United States far outstrip any other industrialized nation and the low-income sector of our communities is rapidly expanding. Therapists attempting to meet the mental health needs of this population face a major challenge given the funding cutbacks being experienced in many areas. Even when adequate funding can be obtained, low-income clients are less likely to seek out treatment and are less likely to remain in treatment despite their need for services. Satterfield (1998) discusses some of the reasons for this (including the attitudes of both low-income clients and therapists working with them) and then describes an empirical test of a treatment approach designed to increase the effectiveness of CBT with this population. Highlights of this approach follow:

Referrals:

• Made by primary care MD or health center staff
• Mental Health Clinic is located near Health Clinic, a clinic volunteer (from the community) escorts the client to make their initial appointment
• When possible, the initial visit is scheduled in conjunction with a medical appointment
• The Mental Health Clinic has a bi-lingual, multi-cultural staff
• Clients receive a reminder call for their initial visit and are encouraged to discuss any questions of reservations about the appointment
• Clinicians help clients problem-solve re transportation, child-care and other practical problems
• No-shows are followed up with a personal letter and phone call
• Clinicians help clients access community services, apply for programs, etc. as well as offering psychotherapy
• Referral sources use a Motivational Interviewing approach to increase motivation for following through on the referral

Pre-Treatment Training Session:

• Education about what treatment involves, the treatment rationale, rules and guidelines for treatment
• Role Induction
• Instillation of hope

Treatment:

• Process-sensitive group CBT
• Active steps taken to increase group cohesion
• 16 weekly, 2-hour group sessions organized in 4-week modules covering the use of pleasant activities and problem-solving to improve mood, using cognitive techniques to improve mood, using positive social contacts to improve mood, and relapse prevention

Results

• This treatment approach resulted in a substantially reduced drop-out rate. 74.6% of the subjects completed all 16 sessions of the treatment group as compared with 42% in a previous study in the same clinic.
• High client satisfaction
• Modest but persistent improvement. (i.e. a 33% reduction in BDI scores, a 16% increase in activity level, a 25% increase in social activity, and a 33% decrease in hopelessness.

Satterwhite, J. M. (1998). Cognitive behavioral group therapy for depressed, low-income minority clients: Retention and treatment enhancement. Cognitive and Behavioral Practice, 5, 65-80.

Replies:

America: don't ya love it?, by Paul Salkovskis, 7/14/98 CBT with Minority Clients (Panel discussion at AABT 2001), by Jim Pretzer, 01/25/02

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