A recent and promising development in the mental health field is the long-overdue recognition that patients on different socioeconomic levels require different therapeutic approaches. Most of the recognized techniques of psychotherapy have been devised by middle-class individuals for use with middle-class patients. Psychologists and psychiatrists at the National Institute of Labor Education, the William Alanson White Institute, and union health centers have shown that many of these methods cannot be effectively applied to low-income people. Recognition of this fact is of special importance today because of the trend toward community mental health centers, which will undoubtedly expand treatment opportunities for individuals at the lower end of the economic scale. Heretofore “blue collar” workers have for the most part been allowed to drift along until serious disorders or dire emergencies arise, and then they have been relegated to city and state institutions. Even when they were offered psychotherapy in community clinics, most of them found the approach uncongenial and dropped out The question, then, is what kind of therapy will be both acceptable and effective with low-income patients. The first step is to recognize that they do require their own therapeutic approach. Typically, middle-class therapy treats the patient’s problem as internal, emotional, and originating in relationships that go back to childhood. The major techniques are discussion, free association, and other verbal methods; and the goal of the therapy is self-understanding and personality growth. The low-income client, on the other hand, believes that the causes of his problem are external and physical, and stem from present situations rather than the past. He expects treatment to eliminate his symptoms and produce specific changes in behavior and physical health. In his eyes the therapist is a physician who will give him concrete directions and practical solutions. He prefers home visits to the formality of the office, and is confused and repelled by too much talk and analysis. If given a choice, he prefers techniques that utilize physical activity and social intercourse.In view of these differences, Riess- man and others strongly recommend that therapists not only make a special study of treatment techniques which will be appropriate to low-income people, but also become familiar with their goals, hopes, traditions, and general style of life.As a consequence of these findings, many changes in the therapeutic process are already being tried. The usual intake procedures have been foreshortened or postponed, and the patient is encouraged to air his problems and feelings as soon as he comes in. This helps to satisfy his need for a down- to-earth approach, and also gives the therapist valuable diagnostic material: “The first stage should be cathartic, supportive, informal, and should provide immediate service and appropriate advice.” (Riessman, 1964)A number of special techniques have been found to be particularly effective during the therapeutic process itself. One of them is role-playing centered around the patient’s specific problems. This approach has long been popular in educational programs of labor unions, and is well suited to the low-income client’s interest in group action and interaction. It also encourages the patient to express himself openly and creates an informal setting which brings the therapist into closer rapport with the patient’s way of life. A second approach is to make full use of nonprofessional auxiliaries, or “indigenous nonprofessionals,” drawn from the same background as the client himself. This “helper principle” is effective because it establishes a bridge between the therapist (who is usually a middle-class individual) and the client’s life at home.A third technique has been called “personality adjustment through social action” (Wittenberg, 1948). It has been found that low-income people greatly benefit from becoming involved with labor unions, block committees, hobby groups, or religious activities. Activity of this kind gives them the strength to handle their psychological difficulties, and reduces dependence on the therapist.In addition to these techniques, these clients have been found to derive psychological benefit from auxiliary physical treatments, because of their general belief that their problems are physically caused. The therapist therefore includes tranquilizers, diets, and muscle relaxation in his treatment program.During the past few years a number of large unions have begun to offer mental health service to their members on an organized basis. One promising example is a project carried out by the Hillman Health Center of the Amalgamated Clothing Workers of America, under grants from the National Institute of Mental Health and the Vocational Rehabilitation Administration (Wiener, 1966). The program is a venture in preventive medicine, since it is designed to enable disturbed workers to hold their jobs while undergoing treatment at co-operating hospitals and, where necessary, to provide for retraining or less taxing jobs. Among the early findings of this project are these:(1) the union health insurance department is an important case-finding source, since workers with emotional problems frequently stay away from their jobs and make insurance claims;(2) the business agent, who organizes and services union members, is not only a logical source for case referrals, but can often serve as a constructive member of the clinical team, since he is in direct touch with both the client and his job; (3) patients sent to clinics for treatment are more likely to “stick” if they are prepared for referral and if the referring agent (the project in this case) has a working relationship with the clinic; (4) the great majority of cases required less than three months of treatment and fewer than eight face- to-face interviews; (5) it is important to have the clinic see the patient immediately, even if the first meeting is brief. It must be recognized, of course, that the treatment goals in this type of program are largely limited to changes in attitude and behavior and do not involve the reconstruction of the personality.A representative case is that of Mrs.R., who walked off the job for no apparent reason, but later returned and within a few hours threw a piece of metal at one of the workers who had “started making faces at me.” The business agent urged her to go to the clinic and called to make an appointment with a psychiatrist. She broke the first appointment, explaining, “If I kept it you would think I was crazy.” Thebusiness agent replied that he did not think she was crazy, but that she had an emotional problem and could be helped. When she again hesitated, he offered to accompany her, and the clinic rearranged its schedule in order to see her immediately. The psychiatrist found that Mrs. R. felt that other people were making grimaces at her in social as well as work settings, and identified her personal problem as one of guilt and anxiety aroused by an extramarital situation. He prescribed a tranquilizer (Stel- azine) and asked her to return to work immediately, making another appointment. the business agent discussed Mrs. R. with the clinic social worker, who was acting as case coordinator. He informed her that she had been employed for nine years as a ticket sewer, a critical and precise operation, and had been an excellent worker. However, during the preceding five months, shortly after her brother had been murdered, she had been mixing up the tickets and had begun to complain that her fellow workers were talking about her. To keep Mrs. R. at work, the business agent accompanied her to the job and enlisted the co-operation of her boss and her fellow workers. The psychiatrist continued the medication and interviewed Mrs. R. weekly, focusing attention on her personal and family problems as well as her feelings of guilt. She soon reported that the other workers were more friendly, and recognized that “All the things people were doing to me, I see now were in my imagination.” After about six weeks of treatment, she appeared calm and relaxed, was working up to par, and treatment was terminated.A second example is the Union Therapy Project organized in 1963 by the William Alanson White Institute in New York City. Recognizing that outpatient treatment is rarely provided for blue-collar workers, thirteen graduates of the Institute banded together and signed a contract with United Auto Workers Local 259 to render ten therapy hours and three hours of social work time in the evenings at a nominal fee to be paid by the union welfare fund. The first step was to educate the union members toward mental health and to correct the prevailing idea that treatment means that the patient is “psycho” or “nuts.” To this end, discussions were held at union meetings and articles were placed in the local’s newspaper. Treatment service was offered as part of the union’s health and welfare plan, and patients were seen immediately instead of being put on a waiting list.In this program, the therapists employ a short-term modified analytic approach geared to an understanding of blue-collar values and outlook on life. Flexibility is maintained, and the therapy is adapted to the patients rather than the patients to the therapy. There is little probing into the unconscious, and in many cases the therapist deals with the family as a group rather than with the patient alone. Regular seminars are held at the Institute to discuss cases and discover the most effective approach and the most helpful type of therapist. As in the Clothing Workers Project, shop stewards are) the chief case-finders, since they are respected by the members and can spot trouble in its early stages.