For many counselors, attrition of clients is a common frustration and concern. For practitioners who specialize in working with certain populations such as low-income mothers, the problem of attrition may become strikingly familiar. The number of no-shows on a counselor’s calendar can negatively affect morale and even the counselor’s financial livelihood.
Because of these outcomes from client attrition, counselors sometimes attribute negative qualities to their clients, such as being uncommitted, flaky or lazy. Though such attributions might seemingly make sense in the moment, they mitigate the role that professionals play in countering attrition.
Given the ubiquity of the concern, what role can practitioners play in decreasing attrition? Framed alternatively, how can agency policies and procedures become more congruent with their target populations, particularly low-income mothers? What can we do as counseling professionals to increase retention?
An ecological frame
The differences in individual and contextual perspectives are imperative when considering how to counter attrition. While an individual frame lends itself to blaming clients, a contextual frame considers myriad issues that may influence clients’ attendance in counseling — for example, scheduling, transportation and child care.
Tackling attrition by using an ecological frame is a necessity when working with low-income mothers. Acknowledging context allows practitioners to diminish blameworthiness of clients and enhance consideration of barriers that may prohibit low-income mothers from participating in counseling.
Though resistant clients will still exist, agencies can take steps to reduce the impact of certain barriers that low-income mothers experience. Simple assessment can help agencies identify the primary characteristics and issues of their target population. Scheduling and transportation options for mothers with limited income should be flexible and creative. Follow-up procedures should be rigorous and consistent, and calculated incentives should be identified. A review of potential benefits, risks and expectations for these clients should be standard. Lastly, building relationships with these mothers augments collaboration and provides opportunities to have discussions around multicultural considerations.
Assessment
Do you know the demographic characteristics of your clientele? Even considering a group as specific as low-income mothers, are they mothers of infants or children of middle school age? Are these mothers primarily African American, Caucasian, Hispanic or from a different ethnic background? How impoverished are they? What percentage of these mothers are employed outside of the home or utilizing public assistance? Detailed intake forms should reflect your target population and collect useful information — for example, age of children, employment status and monthly income — for your specific site.
Furthermore, practitioners should know how long their clients are retained. Specifically, what proportion of clients attend only one session?
Additionally, is your agency or practice systematically investigating the barriers that your clients experience? Are you aware of the barriers that your clients encounter, and do you invite them to share their obstacles to treatment? Acknowledging the barriers that clients experience augments an environment of collaboration and therapeutic rapport.
Though it often elicits feelings of anxiety or boredom, assessment is imperative for all agencies and practices, no matter the size or client load. Practices should know their relative strengths and areas for growth. Program evaluation and assessment do not have to be scary or burdensome. They should be viewed as integral and integrated into everyday activities such as intake forms and client feedback. How can services be improved if we remain blind to our areas of needed growth? Assessment is necessary and can be implemented to help determine what policy changes should be enacted.
Scheduling
Standard 8-to-5 hours may not be the best fit for the schedules of low-income mothers. Later hours may better accommodate mothers who have medical appointments for themselves or their children, school meetings or public assistance appointments throughout the day. The availability of evening hours may reduce conflicts with other appointments and obligations for these mothers, particularly if the agency also provides child care. Weekend appointments may further increase flexibility for mothers.
In addition, many practices and agencies operate on structured appointments that are scheduled a week or so in advance. Research demonstrates that low-income mothers face a significant number of crises and life stressors that may be incongruent with highly structured, planned appointments. Given that consideration, what policies do you or your agency have in place to accommodate last-minute appointments? Do counselors call low-income mothers who are not scheduled to give them the opportunity to fill upcoming vacancies in the next day or two? Are these mothers called prior to their appointments to remind them and to reschedule them if needed?
These small changes could help reduce missed appointments and facilitate retention by accommodating the fast-paced, chaotic lives of low-income mothers.
Transportation
Low-income mothers are plagued with transportation concerns such as reliance on public transportation or expensive gas prices. As a consideration to mothers who must rely on public transportation, are all staff members at your agency or practice familiar with the local bus routes? Being able to provide accurate information regarding bus routes and times will help clients navigate public transportation. For mothers with access to a vehicle, providing a $5 gas card may help supplement the expenses of gas.
Establishing partnerships with transportation agencies could also provide a beneficial resource to low-income mothers. Public transportation organizations often have vouchers they can provide if counseling agencies reach out to forge partnerships. Human resource agencies are another potential source for partnerships. These agencies provide free transportation for low-income populations to various health-related appointments, usually in a van or small bus. Mothers could schedule a time to be picked up at their home and travel in less crowded conditions. These accommodations are particularly helpful to mothers who would otherwise have to bring children onto public buses. Although partnerships take more initial work and initiative to organize and facilitate, these collaborations can provide huge benefits for clients.
Follow-up procedures
To address the myriad barriers that low-income mothers may experience, counselor practitioners should adopt a perspective that expects and normalizes missed sessions. Sick children, newborn babies, financial emergencies and calls to help out family or other mothers may inhibit regular, structured participation in counseling sessions. In addition to normalizing missed sessions when they are out of clients’ control, counselors should be careful not to take their frustration over missed sessions out on the clients. Missed sessions can and should be addressed with clients. However, avoid punitive, blaming conceptualizations. Instead, reframe the discussion as an understanding of contextual barriers and include problem-solving strategies.
Agencies should develop a weekly follow-up schedule as part of an ongoing strategy, with counselors and staff members responsible for contacting the same clients on a regularly scheduled basis. The continuity of clients corresponding with the same person facilitates rapport and trust. I also suggest implementing a follow-up process at the beginning of each month, which is when many mothers with low incomes receive public assistance benefits and may have increased resources for attending counseling sessions.
Moreover, follow-up procedures should be creative and involve more than phone contact. Text messaging, email and social media should be considered as avenues of communication. Though these methods of contact are not always viewed as “professional,” they are often more congruent with the resources of low-income mothers. Why? Because the client’s phone may be out of service. Wrong numbers may be on file, or phone numbers could have changed. Voice mail boxes may be full or not set up.
Benefits received at the beginning of the month may also affect phone service. Attempting to contact mothers with low incomes during this time frame may increase the probability that they have active phone service. Also, when engaging in follow-up procedures at the end of the month, texting, social media and email may be active on phones even though minutes have been exhausted.
Lastly, obtaining additional phone numbers at intake may assist in efforts to retain these clients. Getting phone numbers on file (along with release of information forms) for clients’ family members and friends may help you to maintain contact.
Incentives
Counseling clients need to feel they are benefiting by participating in services. This is their incentive for continuing. Counselors should be cognizant that incentives can be both tangible and intangible. In a study I conducted, low-income mothers cited material assistance, social support, education/knowledge and maternal well-being as benefits of the services they received at a local agency. Material assistance was the only benefit cited that was tangible.
Practices need to find an appropriate balance of tangible and intangible incentives for these clients. Research demonstrates that material incentives alone do not retain clients as effectively as receiving both tangible and intangible incentives. Clients need to feel that the program is helping them in a meaningful way or they are unlikely to continue attending. Consider what incentives your clients have for continuing to seek your services.
For low-income mothers, both intangible and tangible incentives are imperative. Given their limited access to resources, material assistance can help to alleviate burdens incurred due to lack of capital. Material assistance can take many forms, including physical goods (transportation vouchers, children’s clothing, food) and connections to resources such as referrals to food banks or physicians with sliding scales. As counselors, we naturally tend to focus on intangible incentives such as self-esteem, support, psychoeducation and personal growth. Without question, those incentives retain their value with this population. However, the importance of tangible incentives should not be negated for low-income mothers.
Counselors need to be aware that incentives should begin with the first session. Low-income mothers have limited resources. If they are spending time and money attending counseling, they need to reap benefits from the beginning.
What is your hook for clients? Why should they come back? If our counseling services are not relevant, then they will not return. We need to make the most of each session, including the intake session, to demonstrate to these women how counseling can truly benefit them.
Benefits, risks and expectations
In addition, counselors should be reviewing benefits, risks and expectations with clients in session one. Counselors usually focus on the potential benefits to clients, while negating or ignoring the risks. Clients are already considering the possible risks, however, so counselors should invite these conversations and help honor clients’ concerns. Among the risks clients may be concerned about are a potential lack of progress, getting (or feeling) worse before experiencing relief, a possible breach of confidentiality by the counselor or not connecting with the counselor.
Counselors should also clearly articulate their expectations of clients and allow clients to voice their expectations of them. Demystifying the process of counseling and making clear what clients can expect is imperative. This is empowering for low-income mothers — individuals who are not often empowered by our society. In addition, this opportunity allows counselors to build rapport and trust by being open and honest from the beginning.
Finally, counselors should elicit a commitment from the client. My research shows that low-income mothers often attend one counseling session and then do not return. Do not assume you are guaranteed a second session. After delineating potential benefits and articulating risks, discuss your client’s commitment to counseling. Does she want to continue counseling? If not, what is keeping her from committing? What can you do to help her navigate this decision point?
Another consideration all programs need to ponder is how much their program costs clients. Beyond any expenses associated with the counseling sessions themselves, how much does transportation cost? Are mothers required to pay for child care to attend counseling? If so, these are costs associated with counseling, and low-income mothers factor them in when considering whether to attend appointments. Agencies should be mindful of how they might mitigate outstanding expenses to keep counseling as affordable as possible for these clients.
Building relationships
Facilitating rapport and collaboration is essential to retaining low-income mothers in counseling services. If they do not feel connected, then they will not return. All counseling is grounded in the foundation of a therapeutic relationship, but counselors should remain especially mindful of the various multicultural identities of these women. Honoring and recognizing their uniqueness will help to build the relationship.
Additionally, the awareness of other identities that commonly intersect with low-income motherhood, such as being African American or a single mother, for instance, should be recognized. In our society, how does the experience of a low-income mother who is white differ from a low-income mother of color? What differences arise between single, cohabiting and married low-income mothers? These nuances are important to address in counseling. More important, counselors should be aware of how they personally view and react to these various identities and how their experiences differ from those of low-income mothers.
Understanding these mothers within their contexts means prizing their intersecting identities. Building authentic relationships is otherwise unfeasible. The onus of responsibility to address these differences between the counselor and client is on the counselor. We hold the obligation of initiating the conversation.
Conclusion
As counselors, we must continue to evaluate ourselves and our agencies to determine how congruent we are being with providing effective services to low-income mothers. The responsibility may sometimes be construed as a burden, but attending to the contextual barriers of our clients is arguably a necessity.
Counselors and clients do not live in worlds isolated from other people and society. Rather, we are deeply enmeshed. Just as we do not wish to be extrapolated from our context to be understood, our clients deserve our deepest attempts at comprehending their experiences and lives. Only with mindful attention to a contextual frame can we authentically and collaboratively counsel vulnerable populations.
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Knowledge Share articles are adapted from sessions presented at American Counseling Association conferences.
Kathryn Haynes Owen is a doctoral student in the Department of Educational, School and Counseling Psychology at the University of Kentucky. Contact her at kathryn.owen@uky.edu.
Letters to the editor: ct@counseling.org